Family Connections' Culture Connections Presenter's Application Form

Join Family Connections’ Culture Connections Training Center in advancing mental health and substance use services throughout northern New Jersey. Through comprehensive, specialized training and education, the Center empowers behavioral health professionals, nonprofit organizations, and for-profit organizations with the knowledge, skills, and resources needed to strengthen NCLAS standards and enhance support for the communities we serve across the region.

1. First Name, Last Name *This question is required.

2. Telephone/Mobile Number *This question is required.

3. Email Address *This question is required. This question requires a valid email address.

4. Please share your social media links: (LinkedIn, Instagram, FaceBook, N/A, etc.) *This question is required.

5. Your Presenter's Title *This question is required.

6. Professional License Number or type N/A *This question is required.

7. Organization Name *This question is required.

8. Organization Telephone Number *This question is required.

9. Mailing Street Address *This question is required.

10. Mailing City, State and Zip Code *This question is required.

11. Speaker / Organization Website Address *This question is required.

12. Brief biographical sketch (100 words or less) *This question is required.

13. If you have presented before for Family Connections, please indicate when or type N/A: *This question is required.

14. Title of the proposed presentation (10 words or less) *This question is required.

15. Delivery of Presentation (Please select one) *This question is required.

16. Your Availability for Presentation Dates (If applicable, please share two consecutive dates) *This question is required.

17. Summary / description of presentation (100 words or less) *This question is required.

18. List three to five (3-5) learning objectives of your presentation that demonstrate action and measure (resource: https://www.aswb.org/wp-content/uploads/2018/09/ACE-Handbook-Acceptable-learning-objectives-list.pdf)

19. List, at minimum, five peer reviewed and/or evidence-based practice research references for your presentation (50% or five, whichever is less must be within the last five years): *This question is required.

20. Please list other organization events where you have presented and/or are scheduled to present, including the same title:

21. Please attach your updated resume and your photo. *This question is required.

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22. Please provide the name, organization, and phone number of two (2) references who can attest to the quality of your previous presentations: *This question is required.

23. In submitting this proposal, I certify that I understand if selected, I agree to abide by the deadlines and other conditions of presenting. I understand that my workshop presentation is not a showcase for promoting my business, practice, or product, and I will not sell my products or services from the speaker platform. I have read and understand the statement above. *This question is required.

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