Proposal 1 Information

Program 1 Title: *

Length of Program: *

Program 1 Description: *

Program 1 Applicable to: (check all that apply) *

Owners/Corporate Staff
Administrators
Directors of Nursing
Nursing
Activities Professionals/Therapeutic Recreation
Business Office Staff
Housekeeping/Laundry Staff
Maintenance Staff
Dietary Staff
Therapists (Physical, Occupational, Speech)
Residents/Families
Other

Program 1 Applicable to: Other *

Do you have an audience size “limit”, and if so – please specify:

Detailed Program Description: *

Online/Printed Program Description (if different than above):

The online/printed materials will include your objectives. Please list your objectives using one of the following “list starters”.

Program Objectives: *

Participants will:
Participants will learn:

Program Objectives: Participants will *

(include action statements such as learn, observe, discuss, etc…)

Program Objectives: Participants will learn *

What resources will you need for this presentation (check all that apply): *

Computer
LCD Projector
Flip Chart/Markers
White Board/Markers
Other

What resources will you need for this presentation: Other *

Will you have a Powerpoint (or other applicable program) presentation? *

Yes
No

Will have you have additional handouts? *

Yes
No

Note: All presentations and handouts MUST be submitted to the NHHCA a minimum of one-week in advance of the presentation, unless other arrangements have been made with NHHCA staff.

Will you have additional presenters? *

Additional Presenter 1 Name:

First Last

Additional Presenter 1 Title:

Additional Presenter 1 Organization:

Additional Presenter 1 Biography:

Additional Presenter 2 Name:

First Last

Additional Presenter 2 Title:

Additional Presenter 2 Organization:

Additional Presenter 2 Biography:

Additional Presenter 3 Name:

First Last

Additional Presenter 3 Title:

Additional Presenter 3 Organization:

Additional Presenter 3 Biography:

Please list any program specific honorarium requests:

Proposal 2 Information

Program 2 Title: *

Length of Program: *

Program 2 Description: *

Program 2 Applicable to: (check all that apply) *

Program 2 Applicable to: Other *

Do you have an audience size “limit”, and if so – please specify:

Detailed Program Description: *

Online/Printed Program Description (if different than above):

The online/printed materials will include your objectives. Please list your objectives using one of the following “list starters”.

Program Objectives: *

Participants will:
Participants will learn:

Program Objectives: Participants will *

(include action statements such as learn, observe, discuss, etc…)

Program Objectives: Participants will learn *

What resources will you need for this presentation (check all that apply): *

Computer
LCD Projector
Flip Chart/Markers
White Board/Markers
Other

What resources will you need for this presentation: Other *

Will you have a Powerpoint (or other applicable program) presentation? *

Yes
No

Will have you have additional handouts? *

Yes
No

Note: All presentations and handouts MUST be submitted to the NHHCA a minimum of one-week in advance of the presentation, unless other arrangements have been made with NHHCA staff.

Will you have additional presenters? *

Additional Presenter 1 Name:

First Last

Additional Presenter 1 Organization:

Additional Presenter 1 Biography:

Additional Presenter 2 Name:

First Last

Additional Presenter 2 Title:

Additional Presenter 2 Organization:

Additional Presenter 2 Biography:

Additional Presenter 3 Name:

First Last

Additional Presenter 3 Title:

Additional Presenter 3 Organization:

Additional Presenter 3 Biography:

Please list any program specific honorarium requests:

Proposal 3 Information

Program 3 Title: *

Length of Program: *

Program 3 Description: *

Program 3 Applicable to: (check all that apply) *

Program 3 Applicable to: Other *

Do you have an audience size “limit”, and if so – please specify:

Detailed Program Description: *

Online/Printed Program Description (if different than above):

The online/printed materials will include your objectives. Please list your objectives using one of the following “list starters”.

Program Objectives: *

Participants will:
Participants will learn:

Program Objectives: Participants will *

(include action statements such as learn, observe, discuss, etc…)

Program Objectives: Participants will learn *

What resources will you need for this presentation (check all that apply): *

Computer
LCD Projector
Flip Chart/Markers
White Board/Markers
Other

What resources will you need for this presentation: Other *

Will you have a Powerpoint (or other applicable program) presentation? *

Yes
No

Will have you have additional handouts? *

Yes
No

Note: All presentations and handouts MUST be submitted to the NHHCA a minimum of one-week in advance of the presentation, unless other arrangements have been made with NHHCA staff.

Will you have additional presenters? *

Additional Presenter 1 Name:

First Last

Additional Presenter 1 Organization:

Additional Presenter 1 Biography:

Additional Presenter 2 Name:

First Last

Additional Presenter 2 Title:

Additional Presenter 2 Organization:

Additional Presenter 2 Biography:

Additional Presenter 3 Name:

First Last

Additional Presenter 3 Title:

Additional Presenter 3 Organization:

Additional Presenter 3 Biography:

Please list any program specific honorarium requests:

Educational Program Proposals

Speaker Proposal Form

Step 1 of 2

Presenter Information

Proposal 1 Information

Proposal 2 Information

Proposal 3 Information