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.

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 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.

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 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

__________________________________________________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