New Jersey Prevention Network: Annual Conference Presenter Application

Conference Presenter Application

* Required Field

PRESENTER INFORMATION

*First Name

*Last Name

*Credentials

*Mailing Address

*City

* State

* Zip Code

* Email Address

* Confirm Email Address

* Phone Number (for Conference Day)

* Organizational Affiliation

* Title

*Preferred Communication Method

Phone
Email

* Preferred Pronouns:

Please note: these next 3 questions are optional to answer but are important for grant reporting.

Gender:

Age:

Which of the following best describes you?

* Conference Lunch Option:

ASSISTANT CONTACT INFORMATION (IF APPLICABLE)

N/A

*First Name

*Last Name

* Email Address

* Confirm Email Address

* Primary Phone Number

*Preferred Communication Method

Phone
Email

PROPOSED PRESENTATION DETAILS

*General Topic

* Workshop Title (please note, NJPN will finalize the title prior to the event)

*Workshop Primary Focus

Prevention

Treatment

Recovery Support

Other

*Workshop Target Audience (please check all that apply) :

* Preferred Workshop Date:

*Workshop Training Level

Introductory

Intermediate

Advanced

*In the box below, please describe how the presentation will impact changes in the attitude, the knowledge, or the skills of New Jersey’s addiction workforce.

REIMBURSEMENT REQUIREMENTS

*Honorarium

Required/Preferred
Not Required

*Honorarium

$0 - $500
$500+

*Agency

*First Name

*Last Name

*Mailing Address

Suite/Apt/Unit

*City

* State

* Zip Code

*Checks should be made payable to

*Travel (NJPN Staff will assist in arranging transportation)

Required
Preferred
Not Required

Hotel accommodations will be provided the night before the event.

Comments (if applicable)

RESUME AND ADDITIONAL ATTACHMENTS

*Upload a Document

AUDIO/VISUAL

*Please confirm the equipment you have to deliver a virtual presentation: