Presenter(s):     Home Ph#: 

Work Ph#:     Email:

Current Position & Title:

Address:  

City:           State:     Zip code:

presenter information

presentation title: 

target audience: 

subject area: 

check all that applies to your situation:

which session(s) will you be presenting:      session i (8:40-9:30)    session ii (11:10-12:00)    session iii (12:10-1:00)

(use institute presenter form for each different topic you will present)

one session $50.00   

two sessions--same topic  $75.00

two sessions--different topics  $100.00

one session--multiple presenters sharing same topic $75.00

two sessions--multiple presenters sharing same topic $100.00

Please Note:  The Regional Office of Education will not be furnishing equipment at the Regional Teachers' Institute.    

You must supply your own equipment needs (ie: laptop, overhead, lcd projectors).

Please give a brief description of your topic and it will be included in the printed program.  A sample description is listed below.  Thank You.

SAMPLE: 

Title of Presentation:  Neglect, Abuse, and Reporting---Your Responsibilities!

Your Name and Title

Brief Description of Topic:  This session will focus on signs, symptoms, and the "do's and don'ts" of the DCFS Mandatory Reporting Process.  Includes legal issues and your responsibilities as a teacher.  Participants will receive the Manual for Mandated Reporters.

Audience:  All Teachers

title of presentation: 

your name and title: 

Brief Description of your topic: 

audience: 

title of presentation: 

your name and title: 

Brief Description of your topic: 

audience: 

title of presentation: 

your name and title: 

Brief Description of your topic: 

audience: