CHW Conference Speaker Application form

We are excited you would like to present for our conference! Please note that all speaker applications are due by May 31, 2023. If you are selected as a presenter, you will be required to submit your PowerPoint and citiations no later than June 30, 2023. Information for submitting presentations and citations will be provided if you are accepted to present. Presentation and citations are required to receive continuing education credits from the Pennsylvania Certification Board for Community Health Workers.

Primary Speaker's Name

First NameLast Name

Credentials (CCHW, CHES, BSW, LCSW, MPH, etc.)

Title & Employer*

Address*

City*

State*

Phone Number*

Area CodePhone Number

E-mail*

Confirmation Email

Bio for Speaker # 1*

Bio for Speaker # 2

The title of your session is the first impression for Conference Attendees. Use a concise, but inclusive, title which clearly conveys what you will be presenting and draws attendees' attention to your topic.

Title of Your Session:*

Target Audience*

Please list your presentation goals and objectives. *

Abstract: Your session abstract will tell Conference Attendees why they should attend your session. To be effective and create interest, it should provide a brief, clear, and concise reflection of your presentation’s content. The abstract should only be one paragraph of between 150 to 250 words in length.*

This year we are asking speakers to include some type of interactive activity as part of their presentations. Please let us know what type of activity you will be doing, so we can help make your activity and presentation a success.

Type of presentation activity

As part of the requirments of the Pennsylvania Certification Board, in order to receive Certified CHW credits, we must have a copy of your resume.

Questions about this can be emailed to: eschaffer@ecpennahec.org

Please upload your resume

Browse Files

Presentation day/time preference

Wednesday, September 27th -MorningWednesday, September 27th -AfternoonThursday, September 28th -MorningThursday, September 28th -AfternoonFriday, September 29th -MorningFriday, September 29th -Afternoon

I have verified that all information provided is accurate. and complete*

Yes

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