Date: mm/dd/yy Primary Facilitator's Name: Primary Facilitator's Title: Institution/Company: Complete Mailing Address: Contact Email: Contact Phone Number: Fax Number: Title of the Session: The Summit Planning Committee is seeking individuals to "facilitate" and not "present" since the primary purpose of the summit is for attending media coordinators to network with colleagues and discuss current professional topics in a roundtable setting. The facilitator is expected keep the discussion flowing, answer questions and recommend resources as necessary. The one hour sessions (including a 10-15 minute questions and answer period) will begin at 9:30am and end 3:15pm. Brief Description of Session Proposal: Please provide a brief 200 word or less description of the topic you are proposing. Please List Audiovisual/Equipment Needs : (i.e. set-up for PowerPoint Presentation; computer access for participants; flip charts) If you do not need equipment, please type NONE in the form box. Preferred Session Time:
(We cannot guarantee your session will be scheduled during the preferred time, but will do our best to accommodate you)
Brief Biography of Primary Facilitator : Please provide a short 150 word or less biography using third person narrative. Consider listing your education, your current profession and any additional information relevant to your presentation and/or the conference. #1 Co-facilitator's Name: Please fill this out if you will be having a co-presenter #1 Co-facilitator's Contact Email: #1 Co-facilitator's Brief Biography: Please provide a short 150 word or less biography using third person narrative. Include your title, your place of employment, and any additional information relevant to your presentation and/or the conference. #2 Co-facilitator's Name: Please fill this out if you will be having a co-presenter #2 Co-facilitator's Contact Email: #2 Co-facilitator's Brief Biography: Please provide a short 150 word or less biography using third person narrative. Include your title, your place of employment, and any additional information relevant to your presentation and/or the conference. #3 Co-facilitator's Name: Please fill this out if you will be having a co-presenter #3 Co-facilitator's Contact Email: #3 Co-facilitator's Brief Biography: Please provide a short 150 word or less biography using third person narrative. Include your title, your place of employment, and any additional information relevant to your presentation and/or the conference. Additional Comments:
