Continuing Professional Education Proposal Form

Program Title
(Ten or fewer words)
Learning Objectives
The following information will be used as the basis for the session description on the Web and in other promotional material.

Objective 1

Objective 2

Objective 3
Program Description
Provide 2-3 sentences to explain the session content and rationale for presentation to attendees.This statement may be used in supportive promotional materials for the session and should be reflective of the previously stated objectives.
First Name *
Last Name *
Credentials *  
Academy Member
(please provide Academy member number)
Phone *  
Your Email *

Speaker(s)  Optional  It is not necessary to name a speaker unless you have a suggestion for someone you know is an expert on your suggested topic.

First Name  
Last Name  
Academy Member  
Email Address  
  • Please enter program title
  • Please enter objective 1
  • Please enter objective 2
  • Please enter objective 3
  • Please enter program description
  • Please enter your first name
  • Please enter your last name
  • Please enter your credentials
  • Please enter your Academy Member number
  • Please enter your phone
  • Please enter your email address

Please validate your message below