Common Bond Institute

Presenter Proposal Form
for Breakout Session*

(PLEASE TYPE OR PRINT CLEARLY, AND SUBMIT IN PLAIN TEXT FORMAT TO ALLOW FOR EASY EDITING)
* See Posted Guidelines for Proposals on our website

1. Name & Credentials ___________________________________________________

    Address ______________________________________________________________

                  ______________________________________________________________

    Phone day (    )                                 eve (    )                             Fax (    )                           

    E-Mail:                                                       Web:                                                                

2. The TT Conference is meant to promote and support the cross-cultural study of Transgenerational Trauma through a Global Network of professional study groups. Are you associated with an existing professional Study Group that addresses this issue?  [  ] Yes  [  ] No
     If so, what group and country (organization, professional group, etc.): ________________________
     If not, are you interested in forming or joining a study group?   [  ] Yes  [  ] No

3. Workshop/Presentation Title (for printed program - max. 12 words):

4. Workshop/Presentation Brief Description (for printed program - max. 45 words). Please be clear and direct about what you are going to do:

5. Relevence To Conference Topic And Mission: Please indicate how your presentation is relevant to the topic: "Transgenerational Trauma: Unresolved Communal Wounds and Victim Identities" as well as how it advances understanding, treatment, prevention, and public dialogue and awareness of this issue (use additional paper if needed):

 

6. Theme Category: Please indicate which theme(s) your session most closely relates to (check all that apply):
  [ ] Psycho-Social           [ ] Educational     [ ] Historical/Anthropological                     [ ] Peace Studies
  [ ] Cultural & Religious  [ ] Neurological    [ ] Global Relations/Public Policy & Law   [ ] Other

7. Session Format (Important Note: The TT Conference is an interactive, dialogue oriented conference to promote the most shared learning. All sessions are encouraged to include interaction and direct attendee participation where possible). Check all that apply:
  [ ] Skills           [ ] Demonstration       [ ] Roundtable/Panel   [ ] Multimedia
  [ ] Discussion   [ ] Lecture/Research   [ ] Experiential  

8. Personal/Professional Bio Statement (for printed program - max. 75 words).
Please include credentials/degrees, occupation, and any position. Also include (separately) a current brief resume. *We prefer not to edit longer personal bios, so appreciate keeping within the word limit.
Co-presenters: If you have co-presenters please also include their name and information.

 

 

9. Continuing Education Credits: Will presentation be structured to meet CEC requirements?:
[ ] Yes [ ] No

10. Any Equipment Needed:                                                                      

11. PLEASE NOTE: The TT Conference is an Interactive Dialogue Process meant to build as a learning community over the 4 days of the program toward outcomes and collaboration. As a result we strongly encourage all selected presenters to be with us for all or most of the conference (presenters and dialogue facilitators receive a 20% Discount off the Program Fee) Will you be participating throughout the conference? ______

12. If you are a licensed practitioner, has your professional license or insurance ever been on probation, suspended, or revoked?   
[ ] Yes  [ ] No   If yes, please explain on a separate sheet.

13. TAPING: Conference sponsors periodically tape or photograph presentations for professional use. Please indicate if this is not agreeable (if not indicated it is assumed to be agreeable):   
[ ] I Agree  [ ] I do not Agree

14. A collection of ARTICLES submitted by conference presenters relevant to their presentations is being generated for publication in a virtual journal on our web site. Submissions in advance are requested. Guidelines are provided on request. Would you wish to contribute such an article?   
[ ] Yes  [ ] No

15. ADDITIONAL REQUESTED INFORMATION (*please submit proposal in plain text form to allows for easy editing):
[ ] Full Presentation Description: (approx. 200 - 300 words on separate sheet,
      with description of qualifications and familiarity with the subject)
[ ] A Current Brief Resume for all presenters and co-presenters
[ ] 2 Professional References (names, position, relationship, & contact info.).
       Please include E-mail, as well as phone/fax and mailing address.
[ ] When We Can Reach You (best days and times)

Proposal Submisson
(Presenters receive a 20% Discount off the Conference Program Fee)
Please submit proposals by E-mail (preferred), fax, or land mail to: