Page 1 of 3 2019 Arrowhead EMS Conference & Expo PRESENTATION APPLICATION FORM Date: ______________ Please complete one application form for each presentation. INCOMPLETE FORMS WILL NOT BE CONSIDERED Presenter Name: (REQUIRED) Presentation Title: (REQUIRED) Presentation Phrase (3-5 words): (REQUIRED) Presentation Description: (REQUIRED) Presentation Objectives: (REQUIRED) Target Audience (check all that apply): (REQUIRED) Advanced Life Support CME Basic Life Support Fire Fighter/EMR Pediatric Law Enforcement Medical Director / Physician General
Page 2 of 3 TO BE CONSIDERED AS A PRESENTER, THIS INFORMATION MUST BE COMPLETED IN ITS ENTIRETY. Name: Credentials: Mailing Address: City: State: Zip: Phone: Fax: Cell Phone: Email: Primary Job Title: Primary Agency Represented: Biographical Description (150 words or less): Presenter Fee/Special Requests (please be specific): Will There Be Co-Presenters/Assistants? O YES Ο NO If yes, complete co-presenter information Will Co-Presenters/Assistants Request Payment? O YES Ο NO Co-Presenter/Assistant Name: Credentials: Mailing Address: City: State: Zip: Phone: Fax: Cell Phone: Email: Primary Job Title: Primary Agency Represented: Biographical Description (150 words or less): Co-Presenter Fee/Special Requests (please be specific):
Page 3 of 3 Co-Presenter/Assistant Name: Credentials: Mailing Address: City: State: Zip: Phone: Fax: Cell Phone: Email: Primary Job Title: Primary Agency Represented: Biographical Description (150 words or less): Co-Presenter Fee/Special Requests (please be specific): Audio Visual Equipment: All presentation rooms will be provided with: • LCD Projector • Screen • Lavaliere microphone • Lap-top Computer Additional needs: • AV Equipment:__________________________________________________ • Other:_________________________________________________________ For more information contact Sarah: • 218-726-0070 • sarah@arrowheadems.com Our Project Coordinator will be in touch with you directly by June 1, 2018 if your proposal has been accepted. If you are selected as a presenter, we will send you a contract to complete and return. Online : www.arrowheadems.com Email : sarah@arrowheadems.com Fax : 218-726-0073 Phone: 218-726-0070 Mail : Arrowhead EMS Association 4219 Enterprise Circle Duluth, MN 55811-5719
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