2023 Presentation Application

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Please use this form to submit a presentation proposal for the Vermont/ New Hampshire Society for Respiratory Care educational conference Sept 12&13, 2023. The conference location is Mill Falls Conference Center, Meredith, New Hampshire.

Email *

What is your first name? *

What is your last name *

What is your email address? *

Phone number *

Is your presentation sponsored? *

Yes

If you are sponsored, who is sponsoring and please include a contact person and email

Do you require overnight accommodations? *

Yes

No, covered by sponsor

Will you need travel/ Airfare reimbursed? *

Yes

No, covered by sponsor

If you are flying in, what airport would you be departing from?

What is the title of your presentation *

Has this presentation been registered with the American Association of Respiratory Care previously? *

Yes

I'm not sure

What type of program format will you use? *

Lecture

Panel

Workshop

Seminar

Symposium

What content area does your presentation fall in? (Choose one)

Adult Acute Care

Bioterrorism and Emergency Preparedness

Clinical Practice

Education

Ethics

Management

Neonatal Pediatrics

Patient Safety

Pulmonary Function

Sleep Medicine

Clear selection

What is your professional experience in the topic that you are speaking on? *

Conflict of interest: I have an affiliation or financial relationship/ interest which could be perceived as posing a potential conflict of interest with the educational program *

yes

Conflict of interest: I have a significant relationship with the commercial supporter (sponsor) of the session *

Yes

Conflict of interest: I, or a family member or partner, have a significant financial interest or significant relationship with one or more companies who manufacture pharmaceuticals or medical devices used to treat respiratory patients. *

Yes

Conflict of interest: please list company names and relationship with any organizations which may be a conflict. If there are none, please write NA *

List the learning objectives for your presentation: *

Please include a short introduction of yourself that will be read before your presentation *

A copy of your responses will be emailed to the address you provided.

Submit

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