AC2013 Call for Presentations

A. Title of Presentation:

 
* Please keep title to under 100 characters. While every effort will be made to retain the title as proposed, MCA reserves the right to edit as necessary.

B. Faculty Information:

Please list name and credentials as you want them listed in print.

Primary Presenter:

First Name
Last Name
Credentials
Title
Organization
Address
City State Zip
Phone
Fax
Email
* This email address will be used for ALL correspondence.

Additional Presenters

If more than 2 co-presenters, a separate Microsoft Word document must be submitted. Please provide contact information below.
First Name
Last Name
Credentials
Title
Organization
Address
City State Zip
Phone
Fax
Email
First Name
Last Name
Credentials
Title
Organization
Address
City State Zip
Phone
Fax
Email

Exhibit Information

I am interested in exhibiting at the special rate of $600 offered to presenters.
Please email Jennifer Taylor at jennifer.taylor@midwestcarealliance.org to request an
Exhibit Form and Contract. Deadline for Exhibit form submission is July 31, 2013

Presentation Information

Check here if you have presented for MCA (OHPCO) in the past. Date

Program Area of Emphasis:

Please check all that apply.
  Bereavement Clinical Issues Ethics
  Fiscal Management Management Org Issues Marketing
  Palliative Care Pediatrics Program Development/Outreach
  Psychosocial Issues Research Skill Building
  Spiritual Issues Other - Please specify:

Target Audience

Presentations should target at least one of the following disciplines.
Please indicate most appropriate by checking all that apply.
  Bereavement Staff Board of Directors
  Chaplains/Spiritual Caregivers Executive Director/CEO
  Clinicians (including Physicians, RNs, APNs, Pharmacists
  Leadership Program Developer / Outreach
  Social Workers/Counselors Volunteers / Coordinators
  Other Audiences - Please specify:

Abstract (250 words or less)

 
*NOTE: MCE will develop an abbreviated description from this abstract for use in the Conference Program Brochure.

References

Please include references and resources you would like participants to have information on.
Please list a maximum of 3 titles with author(s) names.
 

Acceptance Agreement

I agree, as the PRIMARY presenter identified in Section B, I will communicate all information to Co-Presenter(s), if applicable. This includes, but not limited to, forwarding bio forms, AV needs, changes in schedule, date/time of presentation. I understand MCE sends all communications to primary presenter only.
I understand if a proposal is selected, the Primary Presenter registration fee for the day he/she presents is waived.
   - denotes required fields