CE Event Request Form

CE Event Request Form

Thanks for providing the following information. If you have questions, please feel free to email janis.ellington@summitbhc.com.

My Name*

My Email*

Title of CE Presentation*

Brief Summary of Presentation*

This needs to be 3 to 5 sentences long in paragraph format. No bullets please.

Learning Objective #1*

Three Objectives Required

Learning Objective #2*

Three Objectives Required

Learning Objective #3*

Three Objectives Required

Additional Learning Objectives

Add any additional Objectives here:

Presenter's Full Name*

Presenter's Credentials*

Presenter's Bio*

5-6 sentences in paragraph form. No Bullets Please.

Date of Presentation*

Start and End Time (Including Time Zone)*

Virtual or In-Person Presentation*

Select or enter value

Location & Address (for In-Person Presentations)

Event Contact Person Name*

Event Contact Person Phone Number*

Event Contact Person Email*

Host Facility/Facilities Name*

Fee to Attend (if any)*

Any other content you’d like included on promotion

Agenda*

Please add the agenda for this event below. This would be a schedule of the program.

File Upload*

You Must Upload:

Presenter's Resume

Presenter's Headshot

Host Facility Logo (or logos)

Drag and drop files here or

Send me a copy of my responses