Beacon Institute - Call for Sessions Form

Affiliated With

Managed by LifeSpan

CALL FOR SESSIONS PROPOSAL FORM

All proposals submitted must contain all requested information. Proposals must be submitted using this electronic form.

* = Required Fields

PLEASE INCLUDE THE FOLLOWING INFORMATION:

1. Relationship to LifeSpan Network (check one):

Member

Nonmember

Please contact me regarding membership

2. Preferred time allotment for session (check all time blocks to consider):

1 hour

1.5 hours

3a. Presenter(s): Please list the names and contact information for ALL presenters. Maximum of 3 presenters per session.

Presenter (1): (primary contact person – see below to add additional presenters)

Name:	*
Title:
Organization:	*
Address:	*
City, State, Zip:	, *
Telephone:	*
Fax:
E-mail:	*

3b. Education/Professional Experience:

Please submit a résumé in Microsoft Word format. Please limit the résumé to include only education (institution, degree, date) and professional experience.

3c. Additional Presenters

Presenter (2):

Name:
Title:
Organization:
Address:
City, State, Zip:	,
Telephone:
Fax:
E-mail:

Please submit a résumé in Microsoft Word format. Please limit the résumé to include only education (institution, degree, date) and professional experience.

Presenter (3):

Name:
Title:
Organization:
Address:
City, State, Zip:	,
Telephone:
Fax:
E-mail:

Please submit a résumé in Microsoft Word format. Please limit the résumé to include only education (institution, degree, date) and professional experience.

4. Title of Proposed Session (10 words or less, as it should appear in print materials). Please try to write a creative, attention-getting title: (theme is “The Stormy Weather Continues: Gain Strategies That Turn Obstacles into Opportunities.”)

Words Used: 0

4b. What are the issues or problems this session will address? (25 words or less):

Words Used: 0

5. Session Summary (50 words or less - Please be clear and specific about experiential learning that will take place):

Words Used: 0

6. Learning objectives and content description (List 3 measurable objectives in operational/behavioral terms): “As a result of this session, participants will be able to describe, define, demonstrate, operate, analyze…” (Hint: do not use the word ‘learn’ or ‘understand’; applications for CEUs are particular on this.)

* FOR NURSING SESSIONS ONLY - Complete the nursing curriculum form and email to ejones@lifespan-network.org

7. Level of Instruction (check one only):

Introductory

Intermediate

Advanced

8. Intended Audience (check all that apply): Required Field

	Skilled Nursing Facilities/LTC
	Assisted Living Facilities
	Independent Living Facilities
	Continuing Care Retirement Communities
	HUD Housing Facilities

9. Audience Members Within Facilities (check all that apply):

	Activities / Volunteers		Marketing / Public Relations
	Admissions / Social Work		Marketing / Development
	CEO / Administrator		Nursing
	Chaplains		Plant Environmental Services
	Dietary / Dining Services		Resident Services
	Financial / Business		Social Services
	General		Service Coordinators
	Human Resources		Trustees
	Other

10. AV Equipment Required:

	Flip Chart		Lapel Microphone
	LCD Projector		VCR
	Podium		Screen
	Overhead Projector		Laptop

11. Track Topics (that your material is representing): Required Field

Check up to two areas:

	Board Development		Quality
	Leadership/Management		Customer Service
	Disaster Planning		Regulatory/Policy/Legislative
	Risk Management		Survey and Certification
	Nursing/Clinical		Women’s Issues/Leadership
	Culture Change

12. Would you like to serve as a session moderator?

YES

This is a great opportunity to increase your organization’s visibility among conference attendees! You’ll work with senior care professionals and make contacts with attendees!

Moderating a session involves introducing yourself, your organization and the speaker(s) and seminar topic. LifeSpan provides specific guidelines. Seminar evaluations are distributed and collected by moderators. Continuing education credit requirements include ensuring that attendees are present for entire seminar by scanning/punching them as attendees enter and exit sessions; moderators oversee this compliance. Please contact Jennifer Miller by email jmiller@lifespan-network.org or phone 410-381-1176, ext 231 if you have questions.

Close Description

13. Conflict of Interest Form: (ALL presenters must complete and hand-sign a copy of the Conflict of Interest form)

Fax completed form to Enid-Mai Jones, Director of Education at 410-381-6061.

14. Read and Sign:

I understand that I will not receive a speaker fee or reimbursement for expenses (travel, lodging, meals) associated with attending and facilitating this conference or program. I will inform all co-presenters of this policy. LifeSpan will provide the conference/program meal closest to the speaker’s presentation. Presenters may attend other educational sessions on the day of their own presentation at no charge.

Presenters can not obtain continuing education credits for the sessions in which they are the instructor.

I will inform LifeSpan within 60 days of my presentation if for any reason my session will not be given.

Name/Electronic Signature:
Date: