Instructor Application

Name:*

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Contact Information

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Credentials:*

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License Information

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License Expiration Date:*

Biographical Information

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

Instructor Bio:

Statement of Presenter Qualifications:

Please state whether you have presented on this topic in the past at professional conferences or in other professional settings.

Workshop Information:

Do you have a co-presenter?

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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.

Workshop Level:*

Audience specifications – Is any prior training required? Is this training limited to a certain population?

Additional Information (optional):

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