Please submit this form 1 month prior to webinar. Rehearsal webinars should be scheduled two weeks prior to the webinar. APA webinars are a benefit of APA membership. If you have any questions, please contact Laura Turner at laurat@academicpeds.org.

Question Title

* 1. Date(s) of webinar:

Question Title

* 2. Date(s) for rehearsal webinar(s):

Question Title

* 3. Faculty name(s):

Question Title

* 4. Email address(es):

Question Title

* 5. Description of webinar(200 words max):

Question Title

* 6. Learning objectives:

Question Title

* 7. Additional staff support needed (describe additional APA staff time and resources needed besides setting up the webinar, sending out 3 announcements for the webinar and inputting the survey/polling questions into the webinar):

Question Title

* 8. Please include any of the following information to this form:
- Surveys (pre and post)
- Polls
*Please note these should be formatted for Canvas or GotoWebinar

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

Question Title

* 9. Brief bio(s) for webinar leads- (250 words max)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

T