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  • Below is the application to lecture at the 75th Annual Region Three Meeting.  All details for the event are included in this letter, please read the letter in its entirety before completing the application.  If you encounter issues with the application, contact Lara Beer-Caulfield.

    Applications must be received by 12:00 pm on Friday, October 6, 2023.  Applications will be reviewed in mid-October and Region Three will reach out to those whose applications have been accepted this fall.

  • CONTACT INFORMATION

  • CREDENTIALS & MEMBERSHIPS










  • FINANCIAL DISCLOSURES


  • If applicable, check which type of disclosure you need to make and then list the relevant names of the companies/organizations.





  • If you do have a financial interest to disclose, enter the name of the company below that the conflict is with- this area is NOT for you enter your name unless your name happens to be the exact same name as that of the company.

  • LECTURE PREFERENCES & INFORMATION

  • Region Three specifically has an opening on XXX afternoon.  Applications submitted for other times will be accepted and reviewed, and kept on file in case a lecture slot opens up.  Those who apply to speak on XXX afternoon will be reviewed and contacted to indicate if you've been selected to lecture at the meeting.

     








  • Complete the information below pertaining to the lecture(s) you would like to present. You must enter the title and description of at least one lecture and are welcome to complete the information for a second lecture.

  • Topics determined through our needs analysis that we’ve already filled and are NOT looking to duplicate are dermatology, practice management that doesn’t qualify for CECH, wound care, pediatric care, and risk management.

  • CV UPLOAD

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    • ATTESTATION & SUBMISSION

    • By signing your name below, you are signing this application and attesting that you are the speaker applying and not a third party organization submitting the information on behalf of another person.

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    Phone : 717-763-7665
    Fax : 717-761-4091
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    The William L. Goldfarb Foundation 757 Poplar Church Road
    Camp Hill, PA 17011