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2020 Pioneer Network Virtual Gathering presentation:
“Envisioning the Future: 2020 and Beyond”

  • Please be sure you save your work periodically while working on this form, particularly if you will be away from your computer for an extended period of time. 
  • Please complete All fields.  
  • After completion, you will be able to print out a copy for your records. 
  • For questions pertaining to the form or the process, please contact Misty Frank at misty@optplanning.com or call 240-481-3758. For questions pertaining to session content, please contact Joan Devine, Director of Education at  joan.devine@pioneernetwork.net or 636-578-4164. 
  • You will have the ability to complete this form in its entirety or save in steps and complete at a later date. Any information submitted by clicking "SAVE MY DATA" will be saved to the form. NOTE: Deadline for submission is Wednesday, July 1. 

Please indicate the length of the session your submission is for.

Lead Guide/Presenter Information

When considering the number of guides/presenters who will be involved in your presentation, please consider that you want to have ample time to interact with your audience members during the session.  Having more than 1 guide/presenter is always encouraged, and strongly recommended for 2-1/2 or 5-hour sessions. 

A resume or curriculum vitae must be submitted for each guide/presenter for the submission to be considered complete.
First Name:
Last Name:
Title:
Organization / Affiliation:
Address:
Address 2:
City:
State:
Zip:
Country (if other than USA)
Phone:
Cell Number:
Email Address:
Guide/Presenter 1 CV/Resume Upload:
Guide/Presenter 1 Photo/Head Shot Upload:

If accepted as a guide/presenter, this picture will be used on the registration site, on-line program and may be used in Social Media sites managed by Pioneer Network.  A professional photo is not necessary.  A high-quality photo from a cell phone can be submitted.
Additional Email Address for Confirmation:
Presented Before:
Were you referred by someone to submit a proposal?

If yes, by Whom:

Education – Please include basic preparation through your highest degree held.  If not applicable, please indicate NA in the first row across. We want to hear from all.

School #1:
(Name, City and State)		 Degree:
Major Area of Study: Year Awarded:
School #2:
(Name, City and State)		 Degree:
Major Area of Study: Year Awarded:
School #3:
(Name, City and State)		 Degree:
Major Area of Study: Year Awarded:

Pertinent Qualifying Experience in content area / current responsibilities (please limit to 100 words or less)


Words remaining:

Brief paragraph that informs the reader of who you are including your background/experience related to the culture change movement. (please limit to 200 words or less) View bio example


Words remaining:

There will be a second guide/presenter (this section must be completed for the second guide/presenter).

First Name:
Last Name:
Title:
Organization / Affiliation:
Address: Office
Address 2:
City:
State:
Zip:
Country (if other than USA)
Phone:
Cell Number:
Email Address:
Additional Email Address for Confirmation:
Presented Before: No

Education – Please include basic preparation through your highest degree held.  If not applicable, please indicate NA in the first row across.  We want to hear from all.

School #1:
(Name, City and State)		 Degree:
Major Area of Study: Year Awarded:
School #2:
(Name, City and State)		 Degree:
Major Area of Study: Year Awarded:
School #3:
(Name, City and State)		 Degree:
Major Area of Study: Year Awarded:

 

Pertinent Qualifying Experience in content area / current responsibilities (please limit to 100 words or less)


Words remaining:

Brief paragraph that informs the reader of who you are including your background/experience related to the culture change movement. (please limit to 200 words or less) View bio example


Words remaining:

Guide/Presenter 2 CV/Resume Upload

Guide/Presenter 2 Photo/Head Shot Upload

There will be more than two guides/presenters and/or there will be panelists participating in the session.

First Name Last Name Title Organization Email Address

Pertinent Qualifying Experience in content area (please limit to 100 words or less)


Words remaining:

Current Responsibilities in content area (please limit to 100 words or less)


Words remaining:

CV/Resume Upload

First Name Last Name Title Organization Email Address

Pertinent Qualifying Experience in content area (please limit to 100 words or less)


Words remaining:

Current Responsibilities in content area (please limit to 100 words or less)


Words remaining:

CV/Resume Upload

First Name Last Name Title Organization Email Address

Pertinent Qualifying Experience in content area (please limit to 100 words or less)


Words remaining:

Current Responsibilities in content area (please limit to 100 words or less)


Words remaining:

CV/Resume Upload

First Name Last Name Title Organization Email Address

Pertinent Qualifying Experience in content area (please limit to 100 words or less)


Words remaining:

Current Responsibilities in content area (please limit to 100 words or less)


Words remaining:

CV/Resume Upload

First Name Last Name Title Organization Email Address

Pertinent Qualifying Experience in content area (please limit to 100 words or less)


Words remaining:

Current Responsibilities in content area (please limit to 100 words or less)


Words remaining:

CV/Resume Upload

Session Title (Please be brief and limit to no more than 10 words)


Words remaining:

Session Description (Please provide a short summary of your session and intended outcome. This is limited to no more than 100 words. This is what attendees will read to make their decision on which session to attend.)


Words remaining:

Worth noting is that 65% of our conference attendees are "first timers."  We need to provide appropriate sessions for their phase of the journey.  Please check the appropriate category for your session.

Getting Started Sustaining Advanced All

My primary focus of my session supports envisioning the future of or for (check up to 3):

Leadership
Care team members
Families
Elders
Environments
Dementia care
Clinical care and support
Innovation

Target Settings – Select all of the following settings that your session will address:

Adult Day Services
Aging Network Agencies (e.g. Area Agencies on Aging and/or their providers)
Assisted Living
Home Care
Hospice
Hospitals
Memory Care
Nursing Homes
PACE Programs
Rehabilitation/Post-Acute Services
Retirement Communities
Senior Centers
Senior Housing
Wellness Centers
Others, please explain in less than 10 words
           Words remaining:

Primary Audience – Select all that apply

Clinical Staff
Dining Staff
Direct Care Staff
Life Enrichment/Activity Staff
Middle Managers
Ombudsmen/Surveyors/Advocates
Resident / Elders
Senior Leadership
Social Workers
Other, please specify
      
           Words remaining:

List evidence-based reference(s) used in the development of this session.

Please include the following descriptions of each section of your submission:

Objectives - list measurable objectives. Start each with such words as: Apply, Create, Compare, Define, Discuss, Evaluate, List, Name, Plan. Avoid the use of words that are not measurable such as Learn or Understand.

Content (Topic) - List each topic area and a description of content to be addressed. It must be directly related to the corresponding objective. This should be more than a restatement of the objective.

Time Frame: the time frames listed must add up to the total time allotted for the session Guide/Presenter (person(s) completing this portion)

Guide/Presenter (person(s) completing this portion)

Teaching Methods - List methods, strategies, resources materials for each objective. Examples include lecture, panel, discussion, interactive group exercises, case study, role playing, Q&A, use of props, experiential learning.

Objectives Content (Topic) Time Frame Guide/Presenter Teaching Methods

By submitting, you agree that the information you are providing is accurate to the best of your knowledge.  Guide/Presenter acknowledges he/she will not receive a speaker fee or honorarium, however, guides will receive free registration to the Virtual Gathering at no cost. Pioneer Network does ask that each guide assist in the promotion of the Virtual Event, and a Toolkit to support this will be provided.

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