PRESENTER / PANELIST / MODERATOR REQUEST FORM

"*" indicates required fields

(Name as you wish it to appear in print)
DO YOU AUTHORIZE THE RELEASE OF YOUR EMAIL IN THE CONFERENCE PACKET?
PLEASE PROVIDE THE FOLLOWING FOR ANY CO-PRESENTER(S) / PANELIST(S) WHO WILL JOIN YOU:
NAME/DEGREE/CREDENTIALS
JOB TITLE
ORGANIZATION
EMAIL
 
(Title in your confirmation letter is descriptive.)
Will you be preparing / using other materials for attendees?
Will you be preparing / using a power-point presentation?
Please send your power-point presentations and/or other non-copyrighted ‘handouts’ by AUGUST 31 to katie@esimgt.com so they may be posted and ready for attendees to follow during the confer-ence. Then, bring your presentation on your laptop so you can use and reference your materials as you present. (If you will be including anything from the web, please have that embedded so there are no issues with wi-fi connections during your presentation.
TEACHING METHODS (Please check all that apply to meet APA accreditation requirements):*
(ESI may edit for program & posting space purposes.)
OBJECTIVES:
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