SPEAKER AGREEMENT SUBMISSION for the
Metro Speech-Language Symposium
***Presentations must include a financial and non-financial disclosure statement at the beginning of all presentations for all speakers. (For more information on financial and non-financial disclosures as well as examples go to:
Name: (Speaker #1) (Free Registration if presentation is selected)
(Free Registration for 2 accepted speakers per presentation)
*Please provide names, addresses and email addresses for all co-speakers on page 2
District/BOCES: Job Title:
(Include degree and ASHA certification if applicable)
Work Phone: Home Phone:
Home Address:
E-Mail:
Presentation Title:
Presentation Description: In 75 words or less, provide a detailed description of your presentation. This is will be used in the Symposium Handbook.
Learner Outcomes: Please list two learner outcomes for your session
1.
2.
Do you plan on attending the Symposium on Friday? YES NO
Do you plan on attending the Symposium on Saturday? YES NO
--OR--
Do you plan on attending your presentation only? YES NO
Do you need a vegetarian meal? YES NO
Do you need a gluten free meal? YES NO
(We regret that no other dietary needs can be accommodated)
Co-Speaker(s): Please provide the following information on the person(s) presenting with you.
Name: (Speaker #2) (Free Registration if presentation is selected)
District/BOCES: Job Title:
(Include degree and ASHA certification if applicable)
Work Phone: Home Phone:
Home Address:
Email:
Do you plan on attending the Symposium on Friday? YES NO
Do you plan on attending the Symposium on Saturday? YES NO
--OR--
Do you plan on attending your presentation only? YES NO
Do you need a vegetarian meal? YES NO
Do you need a gluten free meal? YES NO
(We regret that no other dietary needs can be accommodated)
Name: (Speaker #3) (Regular Registration Fee)
District/BOCES: Job Title:
(Include degree and ASHA certification if applicable)
Work Phone: Home Phone:
Home Address:
Email:
****Co-Speaker #3 will need to fill out a registration form and submit a payment if they are planning on attending the symposium****
--OR--
Do you plan on attending your presentation only? YES NO
Handouts: Copyrighted material must have publisher/author permission to be included in the handbook. Handouts can be posted on our website in order to allow attendees to print them before arriving at the Symposium.
Audio/Visual Information:
•Provided for each presentation: one LCD projector, screen & microphone
•Do you need Wi-Fi access for your presentation? YES _____ NO______
- Speakers are strongly encouraged to use a Power Point Presentation
- All Audio/Visual needs MUST be communicated with the Symposium staff before the conference. Speakers are NOT to contact the hotel directly to arrange A/V needs. Only requests made to the Symposium staff will be honored.
- Speakers must bring their own laptop is needed for their presentation.
Please rank order your choice of presentation days/times (1st, 2nd, 3rd):
Saturday, am Saturday, pm
The presentation may be recorded in case of inclement weather.
Email your completed Speaker Agreement to: