Workshop Presenter Interest Form
Print and complete this form to express your interest in presenting a workshop or participating in a panel at the November 4, 2011 Conference that will be held at Metcalfe Federal Building, 77 W. Jackson Boulevard, Chicago, Il.
Name:_____________________________________________
Title:_____________________________________________
Organization:_____________________________________
(if your organization sells products and services see the
Vendor workshop information below)
Address:__________________________________________
City:_________________State:________Zip:__________
Phone:_______________________
Fax:_________________________
Website:__________________________________________
E-mail:___________________________________________
Please provide the following information (use a separate page as needed):
1. Proposed Workshop Title (subject to editing by T/MC)
_________________________________________________________________
2. Session
Description—Please provide a clear, concise 50 word summary
that tells participants what to expect from the workshop. This will be
used on the conference website, invitation, and program book.
3. Provide
a detailed description of your workshop, who it is intended to serve
(leaders, volunteers, etc.), and one or two lessons participants might expect to
take away from the workshop.
4. Provide
a brief (100 word maximum) biography of each presenter and the
organization you represent. If you or your organization are selling
products and services, please review the sponsor agreement below.
5. To what level of experience is this presentation directed? :
_____
Beginner _____
Advanced
_____ Both
6. If your workshop is focused on organizations working with specific age groups, please indicate which age levels the workshop targets:
Grade
levels:
_____ K-5th grade _____ 6th-8th grade _____ 9th-12th grade
7. Audio Visual Needs: Please check only those items necessary for your presentation. The T/MC will make every effort to meet your request, but may need to discuss unusual requests on a case-by-case basis.
_____ No equipment needed _____ Flip chart and pens
_____ Overhead projector and screen _____ Carousel slide projector
_____ VCR and monitor _____ LCD Projector ______ Laptop
NOTE: The T/MC has limited capacity to provide LCD
projectors and laptop computers. If you are not able to provide your
own LCD projector or laptop, contact the T/MC for further guidance.
Presenter Release
By completing and submitting this form, I am agreeing to the following:
I agree that any photos taken of me during this event can be used on the Internet to help T/MC promote future Conferences and tutoring/mentoring.
I agree that parts of my workshop can be filmed, and that parts or all of that video can be put on the Internet for promotional, educational, or motivational use. Note: The T/MC will not make video copies of more than a few minutes of any speaker's presentation.
Signature of Primary Presenter
__________________________________________________Date ________________
Please mail or fax to:
Tutor/Mentor Institute, LLC
Tutor/Mentor Connection
Merchandise Mart PO Box 3303
Chicago, IL 60654
Fax 312-787-7713
