2017 Summit-to-Sound Speaker Information: Out of Town


Please complete the information below as you would like it printed in our promotional materials.

Please complete this form by Dec. 15, 2016

Name:*
Professional Title:
Group/Hospital:

Contact Information

Address:
Phone:
-
Cell:*
-
E-mail:*

Presentation Learning Objective Statements

At the conclusion of this presentation attendees will be able to:

Title of Presentation #1:*
Learning Objectives for Presentation #1:*
Title of Presentation #2:
Learning Objectives for Presentation #2:

Compensation

The WA-ACEP agrees to provide faculty with complimentary meeting registration, $500 honorarium, two nights accommodations at The Edgewater Hotel, airfare, meals, mileage and parking. Please indicate the nights you would like hotel accommodations:

Hotel Accommodations:
Room preference:
I plan to stay through the weekend and would like additional hotel reservations for the following nights:
I plan to bring a guest(s):
Name of guest(s):
I would like to attend the WA-ACEP Board Meeting at 5:30 pm on Wednesday, April 26:
I would like to attend the WA-ACEP Faculty Dinner at 7:30 pm on Thursday, April 27 at the Edgewater Hotel:

Audio/Visual

We ask that you bring your presentation on a flash drive. For your presentation, WA-ACEP will provide a podium, microphone, screen, LCD Projector, and laptop computer.

Laptop Preference:
Other A/V Requests:

Syllabus Materials

All speakers are required to provide contributions for the CME E-Syllabus. Please submit your contributions no later than March 31, 2017.  In addition to submitting the materials via this form, you may email them to plp@wsma.org or send via Dropbox.

Submit a brief bio:
Submit your course materials:
Please verify:

Questions?
Contact Pauline Proulx at 206-956-3648 or send an email to plp@wsma.org