Satellite Symposia Submission Form 2010

Satellite Symposia Submission Form 2010

October 14 - 16 Vancouver Convention Centre, Vancouver BC

Submitted by:

	Provider (Organization e.g. Physician group, university etc. responsible for the overall event)
	Supporter/Sponsor (Industry Partner) Supporters must exhibit at the FMF 2010 in a minimum 1 regular booth space. If the event has more than one supporter, only one is required to exhibit.
	Activity Organizer (third party agency):

Contact Information:

Salutation:

First Name:

Last Name:

Company Name*

Address 1:

Address 2:

Address 3:

City:

Province/State:(Ex: ON = Ontario)

Country:

Postal/Zip Code:

Phone:

Fax

Email:

Additional Contact Information: List contact information of additional supporters/sponsors and co-marketing companies. Also, identify Primary Contact for all FMF Satellite Communication if that individual differs from the one above

Submission Title:

Length 60 minutes (1 Mainpro-1 hour)
Scheduling: Preferred presentation day

	Thursday
	Friday
	Saturday

Scheduling: Preferred presentation time

	6:45am
	12:15 - 1:15 pm (lunch hour)
	17:30 (available Thursday only)

Satellite symposia description/abstract including learning objectives (to be published in FMF printed Program). Maximum 150 words:

Please describe all relevant financial relationships with any commercial interests related to the presentation topics.

Principal Presenter:

Salutation:

First Name:

Last Name:

Credentials: (Ex: MD, CCFP, CCFP(EM), MCFP, FCFP, PhD, etc)

City:

Province/State: (Ex: ON = Ontario)

Email:

Co-presenter:

Salutation:

First Name:

Last Name:

Credentials: (Ex: MD, CCFP, CCFP(EM), MCFP, FCFP, PhD)

City:

Province/State: (Ex: ON = Ontario)

Email:

List additional presenters: (presenter names will appear in FMF printed program)

Has this workshop been presented before?

	Yes
	No

If yes, when and where?

Does this session have Mainpro-M1 accreditation?

	National M1 accreditation
	Alberta M1 accreditation

Expiry date of existing accreditation

If “No”, has this program been previously accredited? Please note the expiry date that accreditation

If “No” has the application process begun?

	Yes
	No

NOTE: All Satellite Symposia must receive Mainpro-M1 accreditation before being presented at FMF. Programs that have national accreditation do not have to reapply.

Applications for National M-1 accreditation should be submitted to the College of Family Physicians of Canada for review by April 9, 2010. Applications for Provincial M-1 accreditation should be submitted to the BC College of Family Physicians for review by March 30, 2010.

The deadline for accreditation is August 31st, 2010. If the session does not receive Mainpro-M1 accreditation, it cannot be presented at FMF. For more information on the accreditation process, click hereand scroll down to review Mainpro - Information for CPD/CME Planners

Does this workshop have room setup or audio visual requirements that may impact the time required to prepare the space. (Standard room set: rounds of 10, riser, podium.)

What is the preferred participant enrolment number for this workshop?