Instructor Application

Name:*

First Last

Contact Information

Address:*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone:*

Email:*

Credentials:*

M.S.W.
Ph.D.
M.Ed.
M.D.
Other

Other:*

License Information

License Number and State:*

License Type:*

License Expiration Date:*

Biographical Information

Name and Degree (as you would like it listed):*

Instructor Bio:*

Workshop Information:

Do you have a co-presenter?*

Yes
No

Workshop Title:*

Workshop Description (approximately 100-150 words):

Workshop Schedule:*

Include time allotments for each topic or section.

Instructional Methodology:*

Lecture
Audio/Visual
Case Presentation
Discussion Groups
Online Presentation
Other Interactive Exercises (please specify)

Other:*

Brief Bibliography (3-5 citations):*

Sources must be from within the last 5 years. A majority of citations should be peer-reviewed and inclusive of the current literature on the topic.

List the Learning Objectives (# appropriate for length):*

Each goal must include a numerical value or quantitatively measurable outcome, and only use the following verbiage: List, describe, recite, write, identify, compute, discuss, explain, predict, apply, demonstrate, prepare, use, analyze, design, select, utilize, compile, create, plan, revise, assess, compare, rate, critique.

Additional Information (optional):

Please upload your CV:*

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