Proposal Student Conclave Education form

Proposal Student Conclave 1 hr Educational Presentations

Name:

Email:

Phone:

APTA #

Prof. Designation

Employer/Occupation

Presentation Title

Description (100-200 words)

3-5 Objectives (At the end of this presentation, the attendee will _________)

References (5 within 10 years, AMA style)

Speaker Biography (50-150 words)

Presentation Disclosure

1. Individual with relationship

2. Describe financial interest and/or entity creating actual or potential conflict

3. Describ relationship between financial interest and/or entity and webinar content

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