Proposal Application
Coalition for Compassionate Care of California
9th Annual Summit
April 10-11, 2018
Anaheim, CA

Theme: Better Together: Forging a path to person-centered care

DEADLINE: 5 p.m., Friday, July 14, 2017

Application must be complete to be considered for review.

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

I would like my presentation to be considered for
Select one.
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 is most appropriate for your presentation.
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.
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