Application to Present

13th Annual Conference on Alzheimer Disease and Related Disorders
November 14, 2008• Crowne Plaza• Springfield, Illinois

Sponsored by Southern Illinois University School of Medicine, Center for Alzheimer Disease and Related Disorders; Illinois Department on Aging and Alzheimer's Association, Greater Illinois Chapter.

All proposals must be submitted to Maggie M. Schaver, SIU-School of Medicine, Center for Alzheimer Disease and Related Disorders (CADRD) on or before January 31, 2008.

1. Speaker Information

Name:
Credentials:
Employer:
Title:
Mailing Address: Street:
City, State, ZIP:
Daytime Phone: ____________________________________ Fax:
E-mail:
This is my Business Address/Phone Home Address/Phone

2. Brief Biography

Please provide a brief biography. This may be submitted as an attachment. If you do not have one, please attach your CV or resume and we will write one for you.

3. Topic/session you would like to present:

If you would like to present more than one topic/session, please duplicate pages as needed and answer Questions 3-9 for each session.

Session Title:

Type of Session: Plenary (45 minutes) Breakout (1.25 hours*)

* The last 5 minutes of each breakout session is reserved for evaluation completion.

4. Session Description

A. Please provide (or attach) a brief description or outline (approx. 75-word) of the content of your presentation.



B. Provide three educational objectives for the session. Please use measurable outcomes. (Tip: complete this statement, "Following this session, attendees will be able to…").

1.

2.

3.


5. If your talk is not for our general audience, please specify your target audience (e.g. specific occupation, family members, etc)?

6. What teaching methodology would you use (% lecture, interactive, etc.)

7. A. What equipment would you like us to provide for you?

NONE VCR/Screen Slide Projector Overhead Projector

Computer LCD Projector Screen Microphone

Table Podium Other (specify):

B. What equipment will you provide yourself?


8. How will you make this session interesting, effective, unique and/or memorable?

 

9. Would you present alone or with others?

I would do the presentation alone.

I would co-present with:

List the names, titles, addresses, phone numbers and employers, if applicable, of your co-presenters:


10 . Compensation requirements


A. Check one:

Conference sponsors will not incur any costs for me to speak.

An organization/company will sponsor the session; conference sponsors will not incur additional costs for me to speak.
Please specify:

I require reimbursement for travel expenses only (mileage, hotel, meals); conference sponsors will not incur additional costs for me to speak.

I require an honorarium of $ per session; conference sponsors will not incur additional costs for me to speak.

I require an honorarium of $ per session and reimbursement for travel expenses (mileage, hotel, meals).

B. To whom should the honorarium and/or expense check be made payable?

C. What is the corresponding social security or FEIN number? (Required for payment).
Please check one: Social Security FEIN

11. Handouts
Presenters are strongly encouraged to provide handouts for their sessions. All session handouts will be included in the conference program book and distributed to each conference attendee. Handouts produced on Word or Power Point may be sent electronically. Hard copy handouts need to be on standard 8 ½ x 11" paper. Handout submission deadline: AUGUST 31, 2008. Please comply with all regulations regarding copyrights.

I will mail original quality handouts prior to August 31, 2008.

I will e-mail my PowerPoint file, from which to print handouts, prior to August 31, 2008.

I will not have handouts to include in the conference program book.

12. Photo
Please plan to submit a photo of yourself (head & shoulders shot).

Return by January 31, 2008 to:

Maggie Mentel Schaver
Center for Alzheimer Disease and Related Disorders
Southern Illinois University School of Medicine
P.O. Box 19643
Springfield, IL 62794-9643

voice: (217) 545-7193 • fax: (217) 545-1903 • email: mschaver@siumed.edu

Page updated August 31, 2007