Workshop Presenter Interest Form
Print and complete this form to express your interest in participating in a panel or hosting a discussion table at the November 4, 2013 Conference that will be held at the Metcalfe Federal Building, 77 W. Jackson, 3rd Floor, Chicago, Il.
(if your organization sells products and services see the Vendor workshop information below)
Please provide the following information (use a separate page as needed):
1. Proposed Workshop Title (subject to editing by T/MC)
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.
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.
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? :
6. If your workshop is focused on organizations working with specific age groups, please indicate which age levels the workshop targets:
_____ 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 conference location provides LCD
projectors. You will need to bring your ownlaptop computers. If you are not able
to provide your own laptop, contact the T/MC for further guidance.
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 and Tutor/Mentor Institute, LLC 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
Please mail or fax to:
Tutor/Mentor Institute, LLC
Merchandise Mart PO Box 3303
Chicago, IL 60654