School/Company/Association: 

Name:                                        

Title:                                          

What is your role with planning this event?  Decision Maker Event Planner Principal/Vice Principal Committee Member Conference Co-ordinator Interested party Other

Address:                                     

City:                                           

State/Province:                          

Postal Code:                              

E-mail:                                       

Phone:       Fax:   

Preferred Speaking Date/Time:

Group to be spoken to
 (for schools, specify what grade; Elementary, Junior High 6-8, or Secondary 9-12)  :    

What is your budget for speakers at this event?

Purpose of Meeting?                

Any Additional Comments?