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Call For Presentations Application

for the 4th Annual Conference, June 2, 2009 to be held at the Aladdin Shrine Center in Columbus, Ohio
To apply to speak at the 4th annual conference in June 2009, complete this form and submit it one of three ways:
  1. Complete it online
  2. Download the Word document then e-mail the completed form to info@centeredcare.org (you may also e-mail this address with any questions)
  3. Fax a completed form to 419-991-0909 ATTN: Susan Marsico.
Deadline for applications: January 15, 2008
Please note: Space is limited. It is likely that the coalition will not be able to accept all applications. There are many successes and many stories to tell about nursing homes in Ohio and we want to hear them all. If your presentation is not accepted this year, please consider saving it and resubmitting it next year.

REGISTRATION INFORMATION
While our goal of this event is not fund raising, but to distribute information, our budget may require presenters to pay a reduced registration fee to attend the entire conference.

Click here to download this form as a Word Document!
Sections with an * are required.

Presentation Title *

Central Domain Information *

This year's convention focuses on the three central domains represented in the Person Centered Care Model: Care Practices, Workplace Practices, and the Environment, all of which surround our residents - the heart of it all! It's important for changes to be made within each domain for organizations to move from an institutional model to that which is person centered. Please check which domains your program addresses:
Care Practices
Workplace Practices
Environment

Target Audience(s):

Please Check All That Apply:
Activities * Activities
Administration
Admissions/Marketing
Dietary
Direct Care
General
Social Service
Other(s)
Level of Sophistication * Introductory (Assumes that the participant has little or no prior knowledge of the areas covered.)
Intermediate (Assumes that the participant has a general knowledge of the literature and professional practice within the areas covered.)
Advanced (Assumes that the participant has a thorough knowledge of the literature and professional practice within the areas covered.
Instructional Methods * Lecture
Panel Discussion
Workshop
Other(s)
Presentation Length: Presentations will be an hour in length.

Learning Objectives:

At the end of this session, partipants will... (list three objectives)
Objective 1 *
Objective 2
Objective 3

Other Details:

Below, include other considerations that the committee should consider when evaluating this presentation.

Session Description: *

Please include a short paragraph describing the session's content. The summary must include a concise description of the content which explains the value of the information and identifies new or unique applications. This information will be used in the promotional brochure that attendees read to choose between the variety of sessions offered during one time frame. You are encouraged to write it in a style that will convince attendees that your session is the one to attend and convince the committee that your session is the one to select!

AV Needs

Please check any audio and/or visual tools you will need for your presentation.
LCD Projector (for use with power point)
Laptop (speaker will provide)
Laptop connection to house sound (if not bringing own speakers)
Handheld Microphone
Lavaliere Microphone
Podium Microphone
Flipchart
Podium/Lectern

Handouts

Deadline for submission of handouts to be included in attendee packets is, April 15, 2009. Please submit handouts to Susan.Marsico@HCFManagement.com. Any handouts submitted after that time will be the responsbility of the presenter.

Presenter 1 Information *
Name *
Title
Organization
Address *
City, State, Zip *
Phone *
Fax
Email Address *
Bio

Presenter 2 Information
Name
Title
Organization
Address
City, State, Zip
Phone
Fax
Email Address
Bio

Presenter 3 Information
Name
Title
Organization
Address
City, State, Zip
Phone
Fax
Email Address
Bio

Presenter 4 Information
Name
Title
Organization
Address
City, State, Zip
Phone
Fax
Email Address
Bio



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Person-Centered Care Coalition
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