Endorsement of Educational Program Application
Organization/Requestor Name
*
Primary Contact Name
*
First Name
Last Name
Email
*
example@example.com
Organization Website
*
Please provide a brief description of the organization's mission
*
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Educational Program Information
Title of the Activity
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Activity Format
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Conference/Meeting
Online Interactive Program
Webinar(s)
Other
Location:
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Start Date
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-
Month
-
Day
Year
Date
End Date
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-
Month
-
Day
Year
Date
Name of Activity Directors/Chairs
*
Have we endorsed your activity before:
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Please Select
Yes
No
When and where?
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Anticipated Number of Attendees:
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Target Audience:
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Is the activity’s location International or National (USA)?
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Please Select
International
National (USA)
Will commercial/industry support or sponsorship be provided for this activity?
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Please Select
Yes
No
If yes, please list all commercial sponsorships below, the actual or requested financial amount of support and how do you plan to eliminate the possibility of commercial bias in the program.
*
Please upload your drafted program/agenda:
*
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Please include the following: - A brief description of the program - Educational objectives of the program - A list of faculty/authors involved in the program - Will continuing education credit(s) be offered? If so which? CME (Physician), CNE (Nursing), CPE (Pharmacy) - Any additional partnering organizations
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of
How does your program support SHEA's Mission or Vision?
*
Check any additional requests for assistance by SHEA, outside the scope of Endorsement:
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Co-Organization - Request for SHEA expert faculty participation
Discounted Membership (International Requests Only) - Request for participants to receive a discount on SHEA Membership for participating in the program
Number of Experts Requested:
*
Will financial support be provided for speakers?
*
Please Select
Yes
No
Submit
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