Complete and submit the following form:

* Name:

* Home Address:


* Town/City:

County:

* State: * Zip code:
Home Phone:

* E-Mail Address:

School:

School Address:


School Phone: * Position:

Local Newspaper:

If you are proposing a session with multiple presenters, please fill in the text area below with the names, addresses, e-mail, and phone numbers of the other presenters. You are responsible for arranging panels on your own. Do not include web addresses in your form responses; the form will be rejected if you do.

Note: sessions are scheduled for one hour each. Please provide time for questions and responses from your audience. In proposing a session, please be aware that you are responsible for arranging all the details and be aware that it should fit the one-hour format. Do not include web addresses in your form responses; the form will be rejected if you do.

* Session Title:

* Description of Session (25-50 word (two sentence) description to appear in the program). Do not include web addresses in your form responses; the form will be rejected if you do.

* Abstract/Rationale: Please give a 150-300 word summary of the content of your session.  Make clear the link (if any) between your session and the theme "Moving Forward/Looking Back-21^st Century Teaching and Learning"  Explain how the audience will be involved. Do not include web addresses in your form responses; the form will be rejected if you do.

Please fill in the text area below with the name, address, e-mail, and phone number of a person you would like to have preside over your session. Do not include web addresses in your form responses; the form will be rejected if you do.

* Format of session (check the one that is appropriate):
Individual Two Person (fill in other presenter's name above)
Group or Panel (fill in other presenters' names above)

* Type of session (check the one that is appropriate):
Workshop Demonstration Panel
Other (specify):

* Grade level[s] to which session is most applicable (check all that apply):
Elementary Middle School
High School College

* General area to be emphasized (check the ONE that will receive the principal emphasis):
Reading Literature Writing
Speaking/Listening Media Language
Curriculum Assessment Technology
21st century Literacy Common Core Standards
Integrated Curriculum Arts and Humanities
Teacher Education Teacher Research
Other (specify):

Additional area to be covered (check ONE):
Reading Literature Writing
Speaking/Listening Media Language
Curriculum Assessment Technology
21st century Literacy Common Core Standards
Integrated Curriculum Arts and Humanities
Teacher Education Teacher Research
Other (specify):

* Session preference, please label your FIRST, SECOND, & THIRD choices of times to present:
Friday Morning (10:00 a.m. - 12:15 p.m.): None FIRST SECOND THIRD Friday Afternoon (12:45 - 4:15 p.m.): None FIRST SECOND THIRD Saturday (9:45 a.m. - Noon): None FIRST SECOND THIRD

Book References: Please list below the authors, titles, publishers, and ISBNs of any books you plan to mention in your presentation. We will try to have these books on hand if we accept your proposal. Do not include web addresses in your form responses; the form will be rejected if you do.

* Denotes a required field.