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C4 Recovery Solutions
Symposium Faculty Submission Form

Proposal Submission Requirements
Proposals will only be accepted via email to Dee McGraw – deemcgraw@ameritech.net.  Please include the following information as your proposal. Failure to include all of the 9 items may result in the Planning Committee rejecting the proposal.

 
 
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Symposium Faculty Submission Form
This Submission is to be considered for:
1. Title:
2. Faculty Name with Credentials:
if multiple Faculty or other contact information please include that here:
3. Workshop Description (Max 300 Words:
4. Objectives: (minimum of 3):
(optional wording has been suggested based on APA guidelines for most appropriate Objectives. An objective describes What the participant will be able to know (knowledge), do (skill), or value (attitudes) after successfully completing instruction. Objectives should be measurable and able to be accomplished within a reasonable time frame). You may submit other objective wording.
Objectives
Objectives:
Objectives:
Objectives:
5. Faculty Bio (Max 250 words)
6.Presentation Length (select all options that might apply)
7. If the presentation makes reference to your organization’s outcomes/evidence-based/scientific practice, please provide a brief synopsis of your data collection/analysis methodology and whether the material was published in a peer reviewed journal.:
Contact Information:
Name:
Phone:
Email:
8. Will honorarium be requested?*
If Yes, what amount (must be specific)?
9. you be sponsored (have any costs covered by another organization)?*
What, if anything, would be covered by your organization?
What, if anything, would you need C4 to cover?
Name of Sponsoring Organization:
10. Please attach updated CV or Resume with this submission.
11. If your organization would also like to purchase an exhibit booth please select here so that we may put you on the waiting list – there is no obligation:
12. Please provide any additional comments that might help the Planning Committee in their decision.
13. If there is additional contact information for faculty please put their name, credentials, email and phone information here for each faculty in the submission:
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    Faculty Submission Form