Behavioral Institute for

Children and Adolescents

Indiana ED Conference Workshop Proposal

April 24-25, 2008

Please submit one form per proposal

DEADLINE FOR SUBMISSIONS:  MARCH 28, 2008

 

Please Note:

  • All presenters and co-presenters must register for the conference. Due to budgetary considerations, it is not possible to offer either an honorarium or a waiver of registration fees to program presenters. Your proposal is an acknowledgement of this requirement.

  • The principal presenter is responsible for keeping all co-presenters informed of all correspondence from BICA and the conference planning committee.

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):

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

CO-PRESENTER 2 contact information (if applicable):

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

 

ADDITIONAL C0-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:

    Workshop (120 minutes)

    Breakout Session (60 minutes)

 

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

    Thursday a.m.

    Thursday p.m.

    Friday a.m.

    Friday p.m.

 

Please use this space to make any notes regarding your presentation preferences and availability:

 

PRESENTATION TITLE:

 

BRIEF DESCRIPTION FOR PROGRAM:

 

TOPIC:

Please select the ONE that best fits

Promising Practices:

    Academic Instruction

    Assessment

    Behavioral Intervention/Positive Behavior Support

    Home-School Partnerships

    Interagency Collaboration

    Mental Health Services

    Use of Technology

Program/School Improvement:

    Staff Training/Development

    School/District-Wide Services

    Program/School Evaluation

Specific Topics/Applications/Research/Other:

    Specific Topics/Applications/Research.  Please specify:

       

 

PROPOSAL:

What is the purpose of the presentation (why is this important and who is the target audience)? What are the objectives (what are you planning to do)? What are the practical applications (how can your results/strategies be used by others)?

 

EQUIPMENT NEEDS:

Please check all that apply.

    Overhead Projector

    LCD Projector

    VCR & Monitor

    DVD & Monitor

    Flip Chart

    Other: 

 

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

 

THANK YOU!

M. Knoll
Copyright © 2008 [Behavioral Institute for Children and Adolescents]. All rights reserved.
Revised: 03/26/08