MSCI Breakout Speaker Participation Form
Please return byMay 10.
*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:
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. The laptops are PCs with CD-Rom drives and USB ports. If you are bringing a presentation on a flash drive or CD, please be sure that it is formatted for a PC that is loaded with Microsoft 2007. If you need additional equipment or supplies, please list below.
______
______
______
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Photocopying: MSCI is intentionally designed to allow for small-sized groups in order to maximize interaction amongst participants and speakers. Breakout 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 fivepages per participant; compile them as a session packet and please observe all copyright laws.
___ Please copy the enclosed materials.
___ I will submit materials to be copied prior to June1. Please copy them upon receipt.
___ 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___ Served Luncheon
___ Keynote Speaker Reception___ Reception
Lodging: Campus lodging is available upon your request for the evenings of June 19through June 21. The cost is $35 per night. If you require lodging, please designate your preferences below. Lodging fees should be mailed with this form by the date indicated below.
I will require lodging for these evenings: Sunday Monday Tuesday
Single room–Female Single room–Male
Married Couple (please indicate spouse name)
Special Needs: We want to make sure that while you are at the Copenhaver Institute, you have your physical needs met. 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 will need lodging that is wheelchair-accessible.
___ Other (Please specify)
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? Only those items marked by an * at the beginning of this form will be included in this directory; no phone numbers or home addresses will be listed. The directory will not be provided to any organization or individual other than MSCI participants and speakers. 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 cannot attend registration on Monday, June 20, 8:30-9:30 a.m., please list the date/time that you plan to arrive to the Institute. Upon your designated arrival time, a staff personor faculty member will meet you in the lobby of the ColketCenter 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 10. Send to:Ms. Linda Lindsay,Roanoke College–Education Department, 221 College Lane,Salem, VA 24153.