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ACPA Discussion Forum Submission Form

ACPA discussion forums are non-CE online events in which attendees have the opportunity to learn, network, and discuss a specific topic. If you are interested in leading a discussion forum, please enter the information below.

1. Please enter your information below.

First Name *This question is required.

Last Name *This question is required.

Institution Name

City *This question is required.

State

Country *This question is required.

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

2. Please indicate which type of discussion forum you would like to lead.

3. What is your primary specialty?
If you are not a medical professional, please enter N/A.

4. Are you a current member of ACPA?

4. Please indicate your experience level.

4. Please indicate if you or a family member are affected by a cleft/craniofacial difference.

Please enter an 'other' value for this selection.

4. List the discussion forum topic you are interested in leading.

5. Briefly describe what the forum agenda would look like.

6. Is there someone else who will lead this forum with you?

7. Are they a member of ACPA?

7. Please list this person's name and email address. If they are a medical professional, include their specialty and institution.

7. Please check all months you are available to lead the forum within the next year.

January
February
March
April
May
June
July
August
September
October
November
December

8. Check all days of the week you are available to lead the forum.

Monday
Tuesday
Wednesday
Thursday
Friday

9. Using Eastern Time, check all times of day you are available to lead the forum.

Morning
Afternoon
Evening