Request for Proposals We are looking for presenters for our June 2023 Summit. "*" indicates required fields Webinar Submission Form All of the following information must be completed in full. Do not email your webinar descriptions. It will not be accepted as a webinar submission. Please Note: Webinars must be open to all people who attend the virtual conference; we cannot restrict attendance to any webinar. Complete Title of Webinar (proper capitalization)* Full contact information of primary contact person for the workshop. If you are submitting for yourself, or submitting on behalf of a group that you are assisting/organizing, you will be identified as the primary contact for the workshop submission. Please share all relevant information that you receive from CHTA to the speakers identified within the submission. Below is all the information we will need from you.Name of Primary Contact for this Workshop Submission* First Last Organization* Main Email* Enter Email Confirm Email Phone Number*(###) ###-#### Please provide a description of the workshop by answering the following questions.This workshop can be categorized as a:* Presentation (1-2 presenters, no moderator necessary) Panel Discussion (3-5 panelists including a moderator. Webinars should have only up to 5 presenters.) Please provide a brief description of the workshop. (Approximately 250 words or less.)*Please review for spelling and grammatical errors before submitting. Objectives*Please provide a numbered list of 3-4 objectives for your webinarWhat is the topic that this webinar falls under ?*(select one)Healthcare, Racial Justice & Public PolicyResearch and TreatmentWomenSex WorkLGBTQIYouth CentralYouth ProviderBehavioral HealthSubstance Use and AddictionHepatitis CPrEPThe Continuum of CareHIV & AgingIf other:* Please provide full contact information for all speakers. Please make sure any speakers that you submit have been contacted and notified prior to your submission. If you are the primary contact person and a speaker, input your data twice. Please submit the following for all speakers Full Name Professional License if applicable (MD, PA, RN/CRNP, LSW, LCSW, CHES, AACO) Organization Primary Phone Number Email Address (this is required) Name*If the person completing this submission intends to be a speaker for the workshop, please complete your details again. First Last Does the speaker hold a professional license?*We submit workshops for continuing education credits and it is critical to include degrees if your speakers have them. Yes No If yes, what profession liscense(s)?MDRN/CRNPCHESAACOPALSW/LCSWOrganization* Phone Number*(###) ###-####Email* Enter Email Confirm Email Brief Bio*(Approximately 150 words or fewer.)Second Speaker Add a second speaker/presenter Name* First Last Does the speaker hold a professional license?* Yes No If yes, what profession liscense(s)?MDRN/CRNPCHESAACOPALSW/LCSWOrganization* Phone*(###) ###-####Email* Enter Email Confirm Email Brief Bio*(Approximately 200 words or fewer.)Third Speaker Add a third speaker/presenter Name* First Last Does the speaker hold a professional license?* Yes No If yes, what profession liscense(s)?MDRN/CRNPCHESAACOPALSW/LCSWOrganization* Phone*(###) ###-####Email* Enter Email Confirm Email Brief Bio*(Approximately 200 words or fewer.)Fourth Speaker Add a fourth speaker/presenter Name* First Last Does the speaker hold a professional license?* Yes No If yes, what profession liscense(s)?MDRN/CRNPCHESAACOPALSW/LCSWOrganization* Phone*(###) ###-####Email* Enter Email Confirm Email Brief Bio*(Approximately 200 words or fewer.)NameThis field is for validation purposes and should be left unchanged. Δ