Workshop Proposal Form 2018

Workshop Proposal Form

Rise Up 2025 - What Now - Our Values in Action!
Primary Facilitator Information
Name*

First NameLast Name
E-mail*
Confirm E-mail*
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Presenter Bio*

If this is included in your attachment, please type "See Attachment"0/500
Will you be travelling from outside of Southern California? If Yes, Where from?*
CIty and State
Degree (if applicable- i.e. BA, BS, Ph.D, MSW, etc.)*
Presenter Resume*

Upload a File
This will be used for our CEU (Continuing Education Units) form Cancelof
Presenter Headshot/Photo*

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This will be used for our website and promotional materials Cancelof
Agency, Company, Organization or School*
Additional Facilitators*

YesNo
If YES, please list the First and Last names (and Email Addresses) of Additional Facilitators
Will a Panel be included?*

YesNo
If YES, please list the First and Last names (and Email Addresses) of Panelists