Webinar Request

Please Fill In All Required Fields

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What type of event is this?

WebinarWorkshop

Personal Contact Info

Your Name

Your Email

Phone

Extension (If necessary)

Today's Date

Event Details

Event Date

Department

Event Title

Start Time of Event

End Time of Event

Event Address (For Live In-Person Workshops Only)

ASHA Section

Are ASHA CEUs offered? (If yes, flyer must include ASHA brand block, financial, & non-financial disclosure)
YesNo

BCBA Section

Are BCBA CEU's offered? (If yes, disclaimer & logo must be included on the flyer)
YesNo

Social Work CEUs

Are Social Work CEUs offered?
YesNo

How many Social Work CEUs?

Patricia Thompson must be notified that Social Work CEUs will be offered for this course. Please contact her, and check the box below to confirm that she has been notified.
(Patricia Thompson can be reached at pthompson@eden2.org or 516-937-1397 x1316)
Yes, Patricia Thompson has been notified.

CEU Totals

Total Cost including CEUs (required)

Disclosures

What Is/Are The Financial Disclosure(s)?

What Is/Are Non-financial Disclosure(s)?

Additional Event Info

Is the event being paid for with a grant?
YesNo

Description of event (please include a 2-4 sentence abstract of the proposed webinar)

Upload an abstract (Optional, PDF file format only)

Event objectives (please include 2-5 webinar objectives for attendees)

Presenter's Name:

Upload Headshot

Title of Presenter as it will appear on the ad:

Company Presenter is employed by:

Who is the target audience? (i.e.:SLPs, Parents, Behavior Analysts, etc.)

Moderator to record event for future use?
YesNo

Additional Information