Annual Conference Speaker Submission Form

First Name *

Last Name *

Organization *

Phone *

Email *

Degree Designation *

Additional Speakers

Title of Presentation *

Speaker Bio *

Please Upload your bio. No more than 100 words (Please provide designation as you would like it to appear on all marketing)

20MB max

Additional Speaker Bio

No more than 100 words (Please provide designation as you would like it to appear on all marketing)

20MB max

2nd Additional Speaker Bio

No more than 100 words (Please provide designation as you would like it to appear on all marketing)

20MB max

Head Shot *

Please upload your head shot. 

20MB max

Additional Speaker Headshot

Please upload the head shot of your additional speaker (if necessary).

20MB max

Additional Speaker Head Shot

Please upload the photo of your second additional Speaker (if necessary)

20MB max

Practice Area *

Practice Area: (Identify the area of physical therapy practice and targeted audience) For Example 1st Choice: - Neurologic Rehabilitation - early career to experience practitioner 2nd Choice: Pediatrics - experienced to advanced practitioner

Session Length *

Enter required value Workshop Single Session - 1 hour Workshop Double Session - 2 hours

Learning Objectives *

Learning Objectives (list 4) - At the conclusion of this session participants will be able to:

Course Format *

Course Format: Describe the format of your session. Include the following elements in your description: instructional strategies and knowledge translation methods and evaluation. (not to exceed 100 words)

Course Description *

Course Description: This is the information that will be printed in the conference materials (not to exceed 250 words):

20MB max

Proposed Schedule for Presentation *

Proposed Schedule for Presentation: List the amount of time you will spend on different areas of your presentation – be specific. The reviewers should be able to visualize what you plan to do during your session. (Example: Introduction & Opening Remarks - 5 minutes, Background Information – 10 minutes, etc.)

Unique Considerations *

 (ex: space, room layout, lab with patients or children involved, equipment or materials needed):

References

 List in AMA style – must have at least 10 references that are peer-reviewed with 50% published within the last 5 years)

20MB max

Previously Presented *

List where & when you have previously presented this session if applicable.

Speaking Experience *

No Prior Speaking Experience

1-2 Presentations

3-5 Presentations

More than 5 Presentations

Previous Presentation Audience *

Workplace Inservice

Local or Regional Event

State Conference

National Conference

NA

Audio Visual Requirements

Please indicate any special audio/visual requirements you may have.

Handout Materials *

I will provide an electronic version of my handout materials ahead of the conference

I will provide an electronic version of my handout materials after the conference

I will not have handouts for my presentation

Photographs *

Do we have permission to use photographs of your at the event for our future marketing materials?

Confirmation *

I understand that speaker presentations for the 2024 Conference will be in-person.  I agree to be present during my presentation time on March 1, 2025. The exact presentation time will be determined by APTA-Oregon.