Speaker Application - Brain Injury Association of MI

Suggested Title*

Rate the Complexity of Your Presentation Topic*

1 - The topic is NOT complex and is appropriate for all participants, though it may be too basic for those already familiar with the topic.
2 - The topic is SOMEWHAT complex and is appropriate for most participants.
3 - The topic is complex and is appropriate for participants already familiar with the topic.

Rate the Level of your Content*

1 - The content is basic or introductory; the content represents general background information.
2 - The content is intermediate; the content is college entry level.
3 - The content is advanced; the content is advanced college level.
4 - The content is very advanced; the content is post graduate level.

Select Suggested Audience Track*

(Please select all that apply)

Business/Administrative
Clinical, if so please clarify
Survivor/Quality of Life
Legal

If Clinical, Please Clarify

(Please select all that apply)

Acute Isses
Ethics
Medical/ Physical
Psychosocial
Special Populations in TBI

Abstract*

Please provide a brief summary (80 words or less) of your proposed session.

Objectives

Please provide at least two objectives for the attendees of your presentation. List the attendee’s objectives in behavioral terms (Opens in new tab). (What the attendee takes away from the presentation)

Objective 1*

Content covered to meet objective 1*

Objective 2*

Content covered to meet objective 2*

Objective 3

Content covered to meet objective 3

Objective 4

Content covered to meet objective 4

Objective 5

Content covered to meet objective 5

Objective 6

Content covered to meet objective 6

First Presenter Information

Name*

First Last

Credentials/Degrees*

Title and Company Name

(if applicable)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cellphone*

Email*

(Required for all presenters, incomplete applications will not be considered)

Biography*

(A brief paragraph for each speaker to be used for introductions in 50-100 words.)

Second Presenter Information

Name

First Last

Credentials/Degrees

Title and Company Name

(if applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cellphone

Email

Biography

(A brief paragraph for each speaker to be used for introductions in 50-100 words.)

File*

- CV/Resume- for each speaker *
- Reference List/Bibliography page- in APA format *
- Conflict of Interest form – for each speaker. If you have not already downloaded and completed the Conflict of Interest form, click here to download.*
- Speaker Headshot(s) (Will be mandatory to submit upon speaker selection)

+ Upload must total 128 MB or less and no more than six (6) files can be uploaded
+ Allowed document file types: pdf, doc
+ Allowed image file types: jpg gif png

- Any other relevant documents

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 50 MB, Max. files: 6.

Name

This field is for validation purposes and should be left unchanged.