Application to Present

10th Annual Dementia Care Conference for Direct Caregivers
Fall 2008• Northfield Center • 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 March 1, 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. 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: Keynote (1.5 hours) Breakout (1.25 hours*)

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

3. Session Description

A. Write a brief description or outline (approx. 75-word) of the content of your presentation. All sessions are 75 minutes long and content should reflect the time frame. You may submit this component as an attachment if more convenient.



B. Provide three educational objectives for the session. Please use measurable outcomes. (Most easily done by completing the statement, "Following this session, attendees will be able to…").

1.

2.

3.


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

 

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

 

6. 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?


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

 

8. Will 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:


9. Past speaking experiences

A. Describe your experience in making presentations and/or teaching to groups:

Very Experienced Somewhat Experienced Inexperienced

B. In what type of settings have you obtained your speaking experience? (i.e. as an instructor/academician, at conferences, etc.)

C. Check one of the following and if you have not presented for SIU-SM, CADRD within the last three years, please list several references we may call regarding your recent speaking experiences and expertise.

I last spoke for SIU-SM, CADRD in __________ (month/year) at the _______________________(event).

I would be a new speaker for SIU-SM, CADRD.

Reference # 1. Name:
Phone Number, City and State:
Organization:
Date and Title/Topic of Presentation:

Reference # 2. Name:
Phone Number, City and State:
Organization:
Date and Title/Topic of Presentation:

Reference # 3. Name:
Phone Number, City and State:
Organization:
Date and Title/Topic of Presentation:

10. Compensation requirements
A. Check one:

SIU-SM, CADRD will not incur any costs for me to speak.

An organization/company will sponsor the session; SIU-SM, CADRD will not incur any costs for me to speak.
Please specify:

I require reimbursement for expenses only; CADRD will not incur additional costs for me to speak.

I require an honorarium of $ per session; SIU-SM, CADRD will not incur additional costs for me to speak.

I require an honorarium of $ per session and reimbursement for expenses. Please specify type of expenses:

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. Handouts should be submitted on standard 8 ½ x 11" paper or may be e-mailed as PowerPoint or Word documents. Please submit your handout on or before September 23, 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

This page updated August 31, 2007