Speaker Name *

Email Address *

CONTACT INFORMATION

Please list how you wish to be listed in the program

Mailing address

Office Phone

Mobile Phone

Home Phone

Fax

Assistant's Name

Assistant's Phone

Assistant's Email Address

BIO (used in the Meeting Program and excerpts taken for verbal introduction)

EDUCATIONAL OBJECTIVES

Objectives are not expected to be exhaustive.  They should make clear the knowledge, skills or attitudes that will be gained by the participant.  Please provide 2-3 objectives for each presentation as a prelude to the presentation and any handouts. 

Title of Presentation: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)

AUDIO VISUAL REQUIREMENTS - I will need the following equipment for my presentation(s):

LCD Projector/Wireless Remote/Laser Pointer

One 35mm slide projector

Two 35mm slide projectors

Video Player - 1/2" tape

Video Player - 3/4" tape

Overhead Projector

Whiteboard and markers, colors:

Flip chart and markers, colors:

Other AV needed:

I will be presenting via Microsoft Power Point (a laptop will be provided)

I will be presenting via Apple Keynote or other software (speaker must provide laptop to run onsite)

I require only voice amplification OR  my presentation(s) will include sound beyond my oration.

I have integrated video into my presentation file (speaker must provide laptop to run onsite)

FINAL PRESENTATION

If you are using Microsoft Power Point and your presentation has NO integrated video, please mail us a copy of your final presentation(s) on CD ahead of the meeting.  Allowing the AV technician to have the presentations pre-loaded on our laptop ensures fewer delays and the meeting running on time.

I will mail a CD of my final presentation(s) by MAY 1 to JCHA - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092

I will email my presentation(s) by MAY 1 to maryann@theassociationcompany.com

HANDOUTS

It is highly encouraged that you supplement your presentation slides with supporting documents, articles, research results, etc.  In lieu of passing out printed handouts during the meeting, we will be mailing CDs with PDFs of the presentations and any additionally provided handouts to all interested attendees after the meeting. 

YES, I will provide handouts and understand that they will be given to attendees via CD.  Please read the following disclaimer and "sign" your name to agree with the statements.

The undersigned Faculty (the “Undersigned”) agrees to:

1.  Grant to the JCHA a nonexclusive, irrevocable worldwide license to reproduce, make derivative works, publish, distribute, and/or sell the recording, transcript, and/or related materials of my presentation. This license does not prohibit the Undersigned from using this presentation in the future for his/her own professional or personal work.

2.  Warrant and represent that, to the best of Undersigned’s knowledge, nothing in the presentation violates the personal rights of others (including, without limitation, any copyright or privacy rights), is factual and contains nothing libelous or otherwise unlawful.

3.  Warrant and represent that the presentation is the Undersigned’s own original work, that Undersigned has the   authority to enter into this agreement, and the Undersigned is the sole copyright holder or that has attained all necessary licenses from any persons or organizations whose material is included or used in the presentation.

4.  Indemnify and hold harmless JCHA from any claims for damages, costs or expenses arising from claims of copyright infringement resulting from the publication, sale, dissemination or distribution of any materials submitted and/or presented by the undersigned, either orally or in writing. The undersigned further agrees to indemnify JCHA against any liability from any statements, oral or written, made by the Undersigned during or after this presentation.

Entering your name in the following space acts as my signature and agreement to the above statement:

Select one option below:

I will mail a CD of my handouts to JCHA - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092.

I will email my handouts to maryann@theassociationcompany.com

Please acquire a copy of my final presentation from me at the meeting to use as my handout.

NO, I will NOT be providing handouts for the CD.