Quarterly CE Application Form

Title *

Speaker Name *

First

Last

Preferred Name/Credentials *

Additional Speaker (if appropriate)

First

Last

Preferred Name/Credentials for additional speaker (if appropriate)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Biography *

Please provide a brief biography or description of yourself. This will be used to introduce you as the speaker.

Speaker Experience *

Speaker Photo *

Click or drag a file to this area to upload.

Please upload your photo to be used on the conference website and platform.

Title of Presentation *

Course Synopsis *

Short Description for handouts and brochure

Course Objectives *

Recommend at least 2-3 measurable objectives. For example, "By the end of this course, participants will be able to identify/describe/list..."

Citations *

My course is relevant to the following scope of OT practice *

You may select more than one.

Level of Presentation *

Presentation Format *

Audio Visual Requirements (select one): *

Handout Materials *

I will provide an electronic version of my handout material to OTAO no later than 3 weeks after the approval of the presentation by OTAO.

In lieu of printed handouts, all handout materials will be emailed attendees to download in advance of the presentation.

Scheduling Preferences *

We will do our best to accommodate your availability

Additional Information

If there is other information you would like OTAO Conference Committee to know, please type here.

FOR MORE INFORMATION:

Occupational Therapy Association of Oregon
Phone: (971)266-4328
Email: info@otao.com