Local Chapter Planning Form

Activity Information

Title of Activity:*

Proposed Date(s) of Activity:

Start Date:*

MonthDayYear

End Date:*

MonthDayYear

Activity Format:*

Location:*

Activity Overview

1. Purpose:*

Please provide the overall purpose of and target audience for this<br>educational activity.

2. Objectives:*

Briefly list 3-5 draft objectives for this educational activity.

Activity Contact Person

Contact Name:*

First NameLast Name

Phone:*

Area CodePhone Number

E-mail:*

Planning Committee

Please list names and credentials of the individuals involved in the planning of this activity:*

Type of Local Council Chapter Education Activity Accreditation Requested:*

CAP (ACCME)CNNT (NYSNA)CRN (ADA- CDR)

Are you working with an NKF office on this program?*

YesNo

Office Name:*

Primary Contact Person:*