KYACHW Conference Speaker Application

KYACHW Conference Speaker Application
The Kentucky Association of Community Health Workers is pleased to announce their 9th annual conference scheduled for Thursday, September 19th and Friday, September 20th, 2024 at the Embassy Suites UK Coldstream in Lexington Kentucky. The theme for the conference is “Keeping the Community in the Community Health Worker” which reflects the impact that CHWs have in their communities.

As a potential speaker please use this form to provide us with additional information regarding your proposed session. Selected speakers will be notified via email and may be asked to provided additional information.
1. Name

First NameLast Name
2. Title
3. Organization Name
4. Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Phone Number (Best number to reach you)
Please enter a valid phone number.
6. Email
example@example.com
7. If you are selected to speak, which time are you available?

Thursday, September 19th between 9am -12pmThursday, September 19th between 1pm-3pmFriday, September 20th between 9am-12pmFriday, September 22nd between 1pm-3pm
8. Have you presented at a KYACHW before?

Yes (move to question 9)No (move to question 10)
9. If so, what was your presentation about?
10. What topic are you interested in presenting at the KYACHW Conference?
11. Which Core Competencies will this presentation build upon? (Select all that apply)

CommunicationUse of Public Health Concepts and ApproachesOrganizational and Community OutreachAdvocacy and Community Capacity BuildingCare Coordination and System NavigationHealth CoachingDocumentation, Reporting, and Outcome ManagementLegal, Ethical and Professional Conduct
12. Type of Presentation

Individual PresentationGroup (go to question 13)Panel (go to question 13)
13. If you have a group or panel presentation give us the names, titles, credentials and contact information for ALL Speakers
14. Please describe how your presentation is related to CHW work?
15. Please list your SMARTIE objectives for your presentation
16. Please provide a description of your presentation
17. Select your length of presentation

One HourThirty minutesOne hour thirty minutesOther (see 17B)Other
17B. Add time
18. How much stipend will you be requesting? (Please note that stipends may not be available)
19. Do you need reinbursed for mileage?

Yes (continue to question 19)No (skip to question 20)
20. How many miles do you estimate you will claim for re-imbursement?
21. Do you need the KYACHW to provide overnight lodging?

Yes (continue to question 21)No (skip to submit)
22. How many people need lodging?
23. How many rooms do you request?
Should be Empty: