MSCI BREAKOUT SPEAKER INFORMATION FORM

Please return byMay 1.

Name: TheRev. Dr. Mr. Ms.

Address:

StreetCity/State/Zip

Work E-mail:Home E-mail:

(Your school Internet security may prevent our e-mails from getting to you; therefore, please include your home e-mail.)

Work Phone:Home or cell Phone:

Job Title:

School:School District:

MSCI Session Title:

● Have you either attended or presented at a previous Copenhaver Institute? Yes No

● Are you either an active or inactive member of KDP International Education Honor Society? Yes No

● Are you a Roanoke College student or alum? Yes No

● Are you a VATOY? Yes No

Brief description of your session (in sentence form) as you would like it to appear in the program (maximum 50 words)

Biographical sketch of yourself (in sentence form)as you would like it to appear in the program

(maximum 50 words)

Supplies/Equipment: Every room will be equipped with a laptop projection system and screen. Please come prepared with your files saved on a jump drive and use our equipment. Our laptops are configured to project properly on our screens; switching to your personal laptop may cause configuration problems. If you need additional equipment or supplies, please indicate: ______

Special Needs: Please indicate below any special needs that you have:

 I would prefer to order a vegetarian meal for the Institute luncheon on June 22.

 I would prefer to order a gluten-free meal for the Institute luncheon on June 22.

 I will need lodging that is wheelchair-accessible.

 Other (Please specify)

Fitness Opportunities:

 Please sign me up for a Tuesday afternoon walk through Salem’s scenic Greenway River Walkway.

Photocopying: MSCI is intentionally designed to allow for small-sized breakout session groups in order to maximize interaction amongst participants and speakers. Sessions generally run approximately 10-30 participants. We will be happy to photocopy materials for your session if they are received at the address below, or emailed as attachments to no later than June1. Please limit your copied materials to a maximum of five pages per participant; we ask that you compile them as a session packet and observe all copyright laws.

 I will submit materials to be copied prior to June1.  I willmake my own copies.

Meals: You are invited to join us for meals at MSCI as our guest. Please designate below the meals that you plan to attend so that we may provide you with meal tickets.

Monday, June 20Tuesday, June 21Wednesday, June 22

 Continental Breakfast Breakfast in Commons  Breakfast in Commons

 Lunch in Commons Lunch in CommonsI will attend the Wednesday

Keynote Speaker Reception served luncheon.

Directory: Do we have your permission to include your name, e-mail address, school and division in a directory that will be provided to fellow participants? The directory will not be provided to any organization or individual other than MSCI participants. It serves as a means for participants to keep in touch with one another following the Institute.

 Yes, I would like to be included in the participant directory.

 No, I would prefer not to be included in the participant directory.

Alternate Arrival Time: If you can’t attend registration on Monday, June 20, 8:30-9:30 a.m., please list the date/ time that you plan to arrive. Upon your designated arrival time, a staff personor faculty member will meet you in the lobby of the Colket Center to provide you with a registration packet and direct you to your session location.

I will arrive after registration on (date/time)

Please complete this formand mail by May 1. Send to:Ms. Linda Lindsay,Roanoke College–Education Dept.,221 College Lane,Salem, VA 24153.