COMMUNITY ASSOCIATES PROGRAM CONFIRMATION
Program Chairman: Complete Areas in Bold
Speaker: Complete areas NOT in bold

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Name of Associate GroupGroup Fund Number

Speaker’s NameSpeaker’s FeeEstimated Travel Fees

Speaker’s Street Address and e-mail address

Speaker’s Telephone and Cell Phone numbersTitle of Program

Duration of ProgramAudience sizeDate of ProgramTime of Program

SPEAKER CATEGORY: AI AII AIII BI BII

AIC/SAIC Employees: Employee Number Employee Department

PTO taken on day of program? Yes No

Make payment to: Employee or Department (if different from above)

Please verify with a BII speaker and with the CA Coordinator that a current W-9 is on file for the BII speaker.

Meeting Site: AddressPhone number

Luncheon Site: AddressPhone number

AIC SPEAKER:Please indicate any of the following items you will be picking up from the Dept. of Museum Education and will return to the department afterwards:

VGA adapter Mac laptop with VGA adapter PC laptop Remote Control device/laser pointer

Note: as a precaution –all speakers are urged to bring a backup copy of any electronic media on a flash drive.

CA GROUPS: Please indicate any of the following items your group will be picking up from the AIC. Follow the directions in the A/V Equipment Guidelinesto complete theA/VRequest Form. Send it to the CA Coordinator as soon as possible.

Digital Projector Remote Control Device/laser pointer

Note: Each Community Associates group will provide: a digital projector, screen, lectern with light, microphone, and proper extension cords (3-prong) for eachprojector and computer.

Signature of Program ChairmanDateSignature of SpeakerDate

Program Chairmane-mail addressPhone or Cell number

In the event that the Program Chairman is unavailable – please contact:

Contact Persone-mail addressPhone or Cell number

Distribute as follows, by August 15:
To the speaker: Program Confirmation and Lecture title forms only for his/her event.
To the group treasurer: Program Confirmation forms only, combined into a single e-mail
To the Group Program Chair and CA Coordinator: All forms, combined into a single e-mail to with “program confirmation forms” in the Subject field.

The Community Associates Lecture Title and Description Form

Program Chairmen: Complete Areas in Bold
Speaker: Complete areas NOT in Bold

Name of Community Associates Group

Lecturer Date of Lecture

(mm/dd/yyyy)

Speakers, please complete this form and send it to the designated Contact Person from the Community Associates group (see your Program Confirmation Form for this lecture)

Lecture Title

Lecture Description for Program Booklet (100 words maximum)

Lecturer's Biographical Information

Please suggest an image to be used for publication purposes (works of art from the Art Institute's permanent collections are preferable):

Artist/Title

AIC accession #

[rev. 2/2016]