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March 11, 12, & 13, 2011– Elk Grove, Village, IL
Program Proposal Application (Use this form only)
PRINT OR TYPE INFORMATION (one seminar or workshop per form)
Submission Deadline: October 15th, 2010
Program Title:___________________________________________________________________________________
o Presentation (50-minute) and/or oWorkshop(2-hour) (attach info and submit photo for workshop)
Format (check all that apply):
oLecture o Discussion oExperiential
Educational Level of Content (check all that apply):
o Beginner o Intermediate o General Public
What will the participant learn from attending your seminar/workshop (brief description/key points for brochure): __________________________________________________________________________________________
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Seminar/Workshop Description (75 words or less for promo material. May be edited for brevity/clarity):
__________________________________________________________________________________________
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Biographical Information (75 words or less, for promo material. May be edited for brevity/clarity):
__________________________________________________________________________________________
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Name:_________________________________________________________________________
Affiliations ___________________________________________________________________
Degree/Titles (fully accredited ONLY)_______________________________________
Address ________________________________________City _________________________
State _______________________________ Zip ____________
Phone ___________________________ E-mail:_____________________________________
(to be listed in promo material)
Business Website (to be listed in promo material): www._______________________________________________
Return to: Art Leidecker
C/O HypnoFertility Foundation, Inc.
1025 Rosewood Dr.
Carpentersville, IL 60110
Any Questions, please call: 224-805-6661
Or by E-mail: worldconference@hypnofertilityfoundation.org
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