APFM 2021 A New Beginning: Reimagining the Art and Science of Family Mediation Conference: October 15-16, 2021Preconference Institutes October 14online via Zoom Quick Conference Navigation Main Page APFM Member Registration Registration (all others) Keynote Speaker Outstanding Mediator Award Lifetime Achievement Award Sponsorship Opportunities Schedule Preconference Institutes Panelist and Moderator Agreement 2021 Moderator Agreement & Release Are you a Moderator or a Panelist? * Moderator Panelist Speaker Info First Name * This will be listed on all conference materials. Last Name * This will be listed on all conference materials. Please include all designations. Textable Phone Number * We need a phone number to which we can text you on the day of the session. Email * Confirm Email * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Moderator Bio * Please include degrees, professional license numbers, expiration dates, and states where they are valid. End with current job description (one sentence). RESUMES / CURRICULUM VITAS Drop a file here or click to upload a copy of your resume or CV Choose File Maximum upload size: 5MB PDFs preferred. Word processing documents and text files also allowed. 5MB maximum upload. Speaker Agreement Participation * I will speak as a panelist or moderator on the panel that I have been invited to join. Technology * I will join the panel via Zoom, using a device with a camera, microphone, and stable internet connection. I will use the Zoom link provided to me and I will not share that link with any person. Expenses * I understand that any expenses incurred to participate in this conference are my responsibility, and I will not be reimbursed by APFM. Registration * I understand that if I wish to attend other panels or workshops, I will need to register for the conference. (Register here.) Notification * I will notify Beth Goldfarb immediately in the event that I am unable to meet my commitment as a speaker and understand that APFM is counting on me to present at the conference. For questions, please contact Beth Goldfarb at [email protected] or 508-735-0961. Content * I warrant and represent that, to the best of my knowledge, nothing in my presentation violates any proprietary or personal rights of others (including, without limitation, any copyright or privacy rights), is factually accurate, and contains nothing libelous or otherwise unlawful. Release I AGREE THAT THE ACADEMY OF PROFESSIONAL FAMILY MEDIATORS MAY: Use of Name and Bio * Use my name and biographical data in any promotional material (print or online) developed in connection with the conference. Use of Content * Reproduce and republish in print, recorded media or online the presentation and remarks of my presentation. For example, video or audio files of my presentations may be provided to conferences attendees free or for a charge. Additionally, the video or audio recording may be given or sold after the conference. Use of Content for Members * Reproduce and republish in any form and in any media tables, charts or other written or visual material used by me as part of my presentation for the benefit of APFM members. In addition, any media tables, charges and other written or visual material from a presentation may include as part of a sale of the video or audio recording after the conference to the APFM membership or members of affiliate organizations. Understanding * I understand and agree to the above conditions. Questions, please contact: Beth Goldfarb [email protected] 508-735-0961 Presentation Content Course content level: * Beginning/Introductory Intermediate Advanced Workshop description: * List 5–7 bullet points summarizing main points of workshop. * List 3 learning objectives. Format as what participants will be able to DO after the session, not what the presenter intends to COVER during the session. * Bibliography Provide 3-4 current (within the last 5 years) scholarly sources that pertain to the content of your panel. Please do not include more than one source of which you are the author. Signature and Agreement Submission Today's Date * Signature * Clear reCAPTCHA If you are human, leave this field blank. Submit
