Please select this button to indicate that you have read and agree to the above noted requirements.

Please provide the following PRINCIPAL PRESENTER contact information:

First Name
Last Name
Middle Initial
Organization
Address Type	Home Work
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone (format xxx-xxx-xxxx)
Home Phone (format xxx-xxx-xxxx)
FAX (format xxx-xxx-xxxx)
E-mail
Confirm E-mail:

CO-PRESENTER 1 contact information (if applicable):

CO-PRESENTER 2 contact information (if applicable):

ADDITIONAL CO-PRESENTERS:

If you have more than three presenters, please use this space to type in their names and addresses (if addresses are the same as other presenters, you may just indicate so).

PREFERRED PRESENTATION TYPE:

Please note that your preference will be considered, but strand leaders will make final selections regarding presentation type and length.

    Breakout Session (50 minutes) Will you accept a poster session if not accepted for a breakout? Please Select Yes No

    Workshop (110 minutes)  The number of workshops is limited. Will you accept a breakout session? Please Select Yes No

    Roundtable or Poster Session (Friday, November 7)

Please indicate if there are any days you are UNABLE to present:

    Thursday

    Friday

    Saturday

TOPIC:

Please select the ONE strand that BEST fits your proposal.

    Assessment/RTI

    Autism Spectrum

    Behavioral/Clinical Interventions

    Coaching/mentoring/professional training

    Community/Interagency Services

    Curriculum and Instruction - Academic

    Curriculum and Instruction - Social Development

    Diversity and Culture

    Families

    Gender-specific Interventions

    Hospital/Residential Services

    Inclusion Services in General Education

    Juvenile Justice/Secure Settings

    Law/Policy/Research

    Mental Health

    Positive Behavior Interventions and Supports (PBIS)

    Transition

    Other.  Please specify:

Please use this space to make any notes regarding your unique presentation needs:

PRESENTATION TITLE:

BRIEF DESCRIPTION FOR PROGRAM:

Please provide a brief (approximately 60-word) description for the conference program.  In your description, please indicate your intended audience (i.e., early childhood, elementary, middle school, secondary, higher ed) and level of the material you will present (i.e., introductory, intermediate, advanced, all levels).

LEARNING OUTCOMES:

Please provide a bulleted list of what participants will learn from this session.

Note: certain CEU providers require specific learning objectives.

PROPOSAL:

What is the purpose of the presentation (why is this important and who is the target audience)? What are you planning to do? What are the practical applications (how can your results/strategies be used by others)? How does this presentation address research-based standards? Please type or cut and paste (up to 500 words)

EQUIPMENT NEEDS:

Notes:

• A screen will be set up in each presentation room and rooms will be set theater-style.

• You are welcome to bring your own equipment, however BICA will not be responsible for any personal equipment used for presentations.

• BICA cannot provide laptop computers.

Please check all that apply. Fees must be paid in advance for selected requests.

    Overhead Projector (no charge)

    LCD Projector ($30)

    VCR & Monitor ($20)

    DVD & Monitor ($20)

    Flip Chart ($15)

    Other: 

SPECIAL NEEDS: Please indicate if you have any special needs or requests.

THANK YOU!