Faculty Speaker Information Form

Contact Information

Name:

Rank:

Department:

Address:   

Phone:

Email:

First Topic

Title of Presentation:

Synopsis of Content

Audio/Visual Requirements:

Appropriate for what Audience? Check all that apply
Grade k-6       Grade 7-12       Other:

Second Topic

Title of Presentation:

Synopsis of Content

Audio/Visual Requirements:

Appropriate for what Audience? Check all that apply
Grade k-6       Grade 7-12       Other:

Third Topic

Title of Presentation:

Synopsis of Content

Audio/Visual Requirements:

Appropriate for what Audience? Check all that apply
Grade k-6       Grade 7-12       Other:

Availability

Check the months you will be on campus and would generally be available to speak:

2008         Jan     Feb     Mar    Apr    May     Jun
                 Jul     Aug     Sep     Oct     Nov     Dec

2009         Jan     Feb     Mar    Apr    May     Jun
                 Jul     Aug     Sep     Oct     Nov     Dec

Summary of Speaker’s Credentials

Please write a brief summary of your credentials in the space below for use when introducing you at speaking engagements.