Proposal Application
Coalition for Compassionate Care of California
11th Annual Summit
April 8-9, 2019
San Francisco, CA

Theme: Communicate | Collaborate | Innovate: Building partnerships in palliative care

DEADLINE: 5 p.m., Friday, September 7, 2018

Application must be complete to be considered for review.

Submission of this application constitutes your agreement to the presenter reimbursement policy.

Email address *
I would like my presentation to be considered for *
Select one.
Required
Primary Presenter Name *
Your answer
Primary Presenter’s Organization *
Your answer
Session Title *
Use a clear and concise title that is informative and clearly reflects the content – 10 words or less.
Your answer
Session Narrative *
Detailed summary of presentation - 500 words or less.
Your answer
Issue or problem session would address *
Use 25 words or less.
Your answer
Session Learning Objectives
List 3 descriptive objectives beyond the session narrative.) Examples: Describe key steps in facilitating a care conference; identify tools for assisting in an advance care planning discussions; discuss the importance of palliative care with patients and families.
Session Learning Objective 1 *
Your answer
Session Learning Objective 2 *
Your answer
Session Learning Objective 3 *
Your answer
Program Area of Emphasis *
Indicate which program area(s) is most appropriate for your presentation.
Required
Target Audience *
Required
Level of Content to be Presented *
Primary Presenter
Email address for each presenter is required.
First Name *
Your answer
Last Name *
Your answer
Job Title *
Your answer
Organization *
Your answer
Street Address *
Your answer
City, State ZIP *
Your answer
Telephone *
Your answer
Email Address *
Your answer
Professional Background *
Provide a brief overview of knowledge and experience related to the proposal and the palliative care and/or end-of-life fields. Please include: Current responsibilities, areas of specialty and past speaking engagements. Additionally, you must paste a resume and/or curriculum vitae. (If you are having problems, email your resume or CV to kscholl@coalitionccc.org.)
Your answer
Co-Presenter #1
Limit 3 co-presenters. Email address for each presenter is required.
First Name
Your answer
Last Name
Your answer
Job Title
Your answer
Organization
Your answer
Street Address
Your answer
City, State ZIP
Your answer
Telephone
Your answer
Email Address
Your answer
Professional Background
Provide a brief overview of knowledge and experience related to the proposal and the palliative care and/or end-of-life fields. Please include: Current responsibilities, areas of specialty and past speaking engagements. Additionally, you must paste a resume and/or curriculum vitae. (If you are having problems, email your resume or CV to kscholl@coalitionccc.org.)
Your answer
Co-Presenter #2
Limit 3 co-presenters. Email address for each presenter is required.
First Name
Your answer
Last Name
Your answer
Job Title
Your answer
Organization
Your answer
Street Address
Your answer
City, State ZIP
Your answer
Telephone
Your answer
Email Address
Your answer
Professional Background
Provide a brief overview of knowledge and experience related to the proposal and the palliative care and/or end-of-life fields. Please include: Current responsibilities, areas of specialty and past speaking engagements. Additionally, you must paste a resume and/or curriculum vitae. (If you are having problems, email your resume or CV to kscholl@coalitionccc.org.)
Your answer
Co-Presenter #3
Limit 3 co-presenters. Email address for each presenter is required.
First Name
Your answer
Last Name
Your answer
Job Title
Your answer
Organization
Your answer
Street Address
Your answer
City, State ZIP
Your answer
Telephone
Your answer
Email Address
Your answer
Professional Background
Provide a brief overview of knowledge and experience related to the proposal and the palliative care and/or end-of-life fields. Please include: Current responsibilities, areas of specialty and past speaking engagements. Additionally, you must paste a resume and/or curriculum vitae. (If you are having problems, email your resume or CV to kscholl@coalitionccc.org.)
Your answer
Submission of application constitutes agreement to the presenter reimbursement policy.
Presenter Reimbursement Policy
Accepted proposals are eligible for discounted registration. CCCC does not pay an honorarium, travel, per diem or other costs for breakout session presenters. In addition, presenters are responsible for all expenses incurred in the development and implementation of their sessions, including reproduction, shipment and delivery of materials.
A copy of your responses will be emailed to the address you provided.
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