New Mexico Symposium on Health Call for Proposals

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Name (Primary Presenter)* This field is required.

First Name

Last Name

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Email* This field is required.

example@example.com

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Organization* This field is required.

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Job Title* This field is required.

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Credentials

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Phone Number* This field is required.

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Mailing Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Linked In Profile

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Please upload your bio* This field is required.

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Max. file size: 10.6MB

10

Please upload your resume or CV* This field is required.

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Please upload your headshot* This field is required.

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12

Will your presentation have co-presenters?

Yes

No

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Co-Presenter

First Name

Last Name

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Co-Presenter Email

example@example.com

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Co-Presenter 2

First Name

Last Name

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Co-Presenter 2 Email

example@example.com

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Co-Presenter 3

First Name

Last Name

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Co-Presenter 3 Email

example@example.com

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Presentation Type* This field is required.

Keynote

Plenary

Breakout Session

Other

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Presentation Title* This field is required.

Please note this is a working title and can be edited after selections have been made.

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Abstract* This field is required.

Please providea brief abstract (250 words or less) summarizing your topic and its relevance to the symposium.

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Length* This field is required.

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Learning Objective 1* This field is required.

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Learning Objective 2* This field is required.

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Learning Objective 3* This field is required.

26

Are you familiar with the CEU approval process for conferences or workshops in your field?

Yes

No

27

Would you like your presentation to be considered for continuing education credit (CEU)?* This field is required.

Yes

No

28

What type of continuing education credits are you seeking to offer for your session?

Certified Community Health Workers

Social Workers

Community Health Education Specialists

Pharmacists

Nurses/Physicians

Counseling

Other

29

Do you agree to follow all required guidelines and timelines for submitting materials necessary for CEU approval, if your session is selected?

Yes

No

31

Requested Honorarium Amount

Constellation Consulting strives to provide equitable honorariums and speaker fees as requested that align with our project budgets.

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Requested Speaker Fee Amount

Constellation Consulting strives to provide equitable speaker fees and honorariums as requested that align with our project budgets.

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Attachment: W9* This field is required.

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Max. file size: 10.6MB

This is required if you are requesting an honorarium or speaking fees.

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Estimated Mileage Amount

35

Estimated Car Rental Amount

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Per Diem Days

Number of days (including travel days)

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Nights of Hotel

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Estimated Airfare Amount

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Previous Speaking Engagements (list organization and presentation topic)

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Link(s) to Resources of Past Presentations (videos or Slideshare)

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Optional -- Attachment: Presentation Examples (PowerPoint)

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Max. file size: 10.6MB

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I affirm that I own or otherwise have the right to use the proposed content. I further affirm that I have the right to give consent to publish the content. By submitting this form, I grant Constellation Consulting, LLC permission to share my presentation with clients, conference attendees and accrediting agencies.
I understand that I will be photographed during my presentation and that my name and likeness may be used for promotional purposes by Constellation Consulting, LLC.

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Signature* This field is required.

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