Workshop Form Expanding Your Horizons printable pdf download

Workshop Form – Expanding Your Horizons - 37

Annual – April 9, 2016

Please complete this form (even if not able to lead a workshop so that you are not called) and return by Monday,

October 23, 2015, to Karen Murie, EYH Coordinator at NDSU, by email attachment (karen.murie@ndsu.edu) or fax

(701-231-7016).

Please complete this section if you are not able to participate in the April 9, 2016 Expanding Your Horizons

____ Please contact me for future conferences (please add your name and address below)

____ Please remove my name from your mailing list

Name: ________________________________________________________________________________________

Address & Email Address: _________________________________________________________________________

Complete this section if you are able to participate in the 2016 Expanding Your Horizons Conference

Title of Workshop (please limit to 5 words or less) _____________________________________________________

Description (please limit to 20 words or less): _________________________________________________________

Contact information (this person will be the main contact for the above presentation):

Name _________________________________________ Email __________________________________________

Work Phone ____________________________________ Cell Phone _____________________________________

Mailing Address _________________________________________________________________________________

We ask that you have assistants for your workshop. Please list all others who will be helping with the above

workshop (and their email and phone number):

Please list any organizations contributing to your workshop _______________________________________________

Please indicate where you plan to hold your workshop and the time of workshop. It is preferred that your workshop

be on a campus. Please remember that transportation is an issue, so will find a location if you can offer the

workshop on a campus. If it is off-campus, you must do a 2-hour workshop (which may not be a full 2 hours because

of transportation time) and must be approved by Director Karen Murie.

Indicate your possible workshop times and location (and indicate in one or two hour workshop):

NDSU or MSUM or Concordia:

AM: ____ 3rd PM: ____

Location – building & room: _______________________________________

AM: ____

4th PM: ____

________________________________________________________

VA:

AM (2 hour workshop) ____

Location & Room Number: ________________________________________

PM (2 hour workshop) ____

Essentia: AM (2 hour workshop) ____ Address & Room Number: _________________________________________

PM (2 hour workshop) ____

________________________________________________________

Sanford: AM (2 hour workshop) ____ Address & Room Number: _________________________________________

PM ( 2 hour workshop) ____

________________________________________________________

Please indicate number of girls per session: Desired number ______ Maximum number _______

Workshop Form Expanding Your Horizons