EmailMe Form - Event Planning Form

UNIT: *

Big Bend

Broward

Central

Chapter

Emerald Coast

Heartland

Lake/Sumter

Miami-Dade

Nature Coast

North Central

Northeast

Northwest

Palm Beach

Palm Beach - South

Palm Beach - North

Sarasota/Manatee

Southwest

Space Coast

Tampa Bay

Treasure Coast

Volusia/Flagler

WHAT KIND OF EVENT: *

CE Licensure Workshop

CE Workshop

Other Event

VIRTUAL, IN-PERSON or HYBRID: *

Virtual (Zoom)

In-Person

Hybrid

ZOOM EVENT STAFFING: After the event is opened, please let us know if you would like your event staffed or not. *

Yes Event Staffed

No Staff Request

EVENT DATE and EVENT START TIME: *

MM / DD / YYYY

EVENT START TIME: *

HH : MM AM/PM

EVENT END TIME: *

HH : MM AM/PM

ADVERTISING/MARKETING: Please create and send out the following items: *

E-Mail Reminders: Please let us know if you have a specific date or dates you want a reminder sent.

ONLINE REGISTRATION: *

Yes

No

Pre-Pay Only

On-Site Payment Allowed

FOR CE WORKSHOPS, PLEASE COMPLETE THE FOLLOWING:

Title of Workshop: *

Presenter Name and Credentials: *

Event Location: *

Event Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Suggested Number of Contact Hours (NASW-FL will make determination):

Workshop / Event Fees: *

CE Licensure Workshop: Member ($15.00 per CEU) Non-Member ($25.00 per CEU) Student Member ($5.00 per CEU)

CE Non-Licensure Workshop: Member ($10.00 per CEU) Non-Member ($20.00 per CEU) Student Member (Free)

Other - Please enter fees below.

Other Registration Fees (include rates for member/non-member/student member)

Workshop Sponsor? *

Yes

No

Workshop Sponsor: If you have a sponsor, please provide the sponsor information.

Sponsor Logo: Please upload the sponsor's logo if it is to be included on the marketing materials. Files types: pdf, jpg and jpeg.

Will food / drinks be provided? *

Yes

No

Food and Drinks: If yes, what kind of food / drinks. Please be as specific as possible - light snacks and soda, lunch, dinner, etc.

Contact Person for Workshop: *

First Last

Contact Person's Email Address: *

Contact Person's Phone Number *

### - ### - ####

Mailing Address to Send CE Packet: This is the person who will receive the mailed evaluations and sign-in sheets.

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

In order to have CE credit approval for this workshop, the presenter's CV/resume, at least one learning objective per contact hour sought and the PPT must be included with this planning form.

The presentation must be reviewed to ensure it adheres to Florida's laws and rules.

The learning objective(s) for this workshop is / are:

Upload Presenter CV / Resume (PDF, DOC or DOCX Files Accepted):

Upload Presentation (PPT and PDF Files Accepted):

If this is an event other than a CE workshop, please give full details. Please include any information that should be included in marketing materials.

Are there any costs that will be associated with this event, such as venue, catering, presenter honorarium, or supplies? If so, please list them here. A separate check request form must be completed when payment needs to be sent. *

Special Request: Please list all specific requests you have for this event. Some examples are: Online registration counts provided on a certain date; maximum number of attendees; and end registration on a certain date.

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