Clinical Conference Instructor Application

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Below is the application to be an instructor at the Goldfarb Foundation's 2018 Clinical Conference. All details for the event are included in this letter, please read the letter in it's entirety before completing the application. If you encounter issues with the application, contact Lara Beer-Caulfield.

All applications submitted by January 8, 2018 at 9:00 am will be reviewed at the Foundation's January Planning Meeting. Applications received after January 8will be reviewed on an as needed basis.

Clinical Conference Instructor Application

CONTACT INFORMATION
Fullname

First Name
Last Name
Title

Address

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Phone
Area Code - Phone Number
Fax
Area Code - Phone Number
Email
CREDENTIALS & MEMBERSHIPS
The Foundation requires all of it's DPM speakers to be active (dues paying) APMA & component society members. Are you currently an APMA member?
Yes
No
I am not a DPM, does not apply
Select below which organization(s) you are a MEMBER of (membership has no bearing on your application and whether you are selected to lecture at a meeting).
AAWC (Association for the Advancement of Wound Care)
ACFAS (American College of Foot & Ankle Surgeons)
APWCA (American Professional Wound Care Association)
ASPS (American Society of Podiatric Surgeons)
None
Other
If you selected "other" above, please list organization(s) here.
Select below which organization(s) you are credentialed by. Certification is not a requirement for lecturing.
ABPM (American Board of Podiatric Medicine)
ABFAS (American Board of Foot and Ankle Surgery)
ABMSP (American Board of Multiple Specialties in Podiatry)
None
Other
If you selected "other" above, please list organization(s) here.
FINANCIAL DISCLOSURES
Disclosures: Select below if you have any disclosures to make, this information will be reviewed by the planning committee.
I DO NOT have an actual or potential conflict of interest in relation to my presentation(s)
I DO have an actual or potential conflict of interest in relation to my presentation(s)
If applicable, check which type of disclosure you need to make and then list the relevant names of the companies/organizations.
Select Choices
Grant/Research Support
Name of organization
Select Choices
Consultant
Name of organization
Select Choices
Speakers' Bureau
Name of organization
Select Choices
Other Financial or Material Support
Name of organization
Select Choices
Major Stock/Share Holder
Name of organization
LECTURE PREFERENCES & INFORMATION
Select your preferred speaking day/timeframe
Friday Morning (8:00 am - 11:30 am)
Friday Afternoon (1:00 pm - 5:30 pm)
Saturday Morning (8:00 am - 11:30 am)
Saturday Afternoon (1:00 pm - 5:30 pm)
Sunday (8:00 am - 1:00 pm)
Does not matter
Complete the information below pertaining to the lecture 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.
Topic area lecture #1 will cover
Biomechanics
Coding/EHR
Dermatology
Diabetes
Diabetic Neuropathy
Legal/Ethics
Musculoskeletal
Plastic Surgery
Sports Medicine
Vascular
Wound Care
Other
Title of Lecture #1
Description of lecture
Enter information relevant to your lecture-objectives, purpose, and what an attendee at the lecture can take away in implement in their practice
Approximate length of lecture #1
15 minutes
30 minutes
45 minutes
1 hour
Is this topic surgical or non-surgical in nature?
Surgical
Non-surgical
Topic area lecture #2 will cover
Biomechanics
Coding/EHR
Dermatology
Diabetes
Diabetic Neuropathy
Legal/Ethics
Musculoskeletal
Plastic Surgery
Sports Medicine
Vascular
Wound Care
Other
Title of Lecture #2
Description of lecture
Enter information relevant to your lecture-objectives, purpose, and what an attendee at the lecture can take away in implement in their practice.
Approximate length of lecture #2
15 minutes
30 minutes
45 minutes
1 hour
Is this topic surgical or non-surgical in nature
Surgical
Non-surgical
CV UPLOAD
CV Upload
Filename
Status
Size
Add Files Start Upload
Upload a copy of your CV for our review. PDF or Word documents only.
ATTESTATION & SUBMISSION
By checking "yes" below and entering your initials, 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.
Select yes below to agree to the terms as stated above.
Yes
Tye your first name, last name, and ttiel (DPM, etc).
By entering your name, it is equivalent to your signature in agreeing to the above terms

The William L. Goldfarb Foundation 757 Poplar Church Road

Camp Hill, PA 17011

Clinical Conference Instructor Application

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.

LECTURE PREFERENCES & INFORMATION

Complete the information below pertaining to the lecture 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.

CV UPLOAD

ATTESTATION & SUBMISSION

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