Innovation Café Speaker Information Form

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If you’re an expert scientist in the fields of engineering, innovation, or any cutting edge science, and you’re interested in doing outreach around the newest "Making Stuff" campaign and broadcast, we’re looking for you!! Science Cafés are a great opportunity to serve your community and to gain a fresh perspective on the issues surrounding scientific practice, policy, and research.

Submit your contact information to the NOVA Education team by filling out this form, and we will contact you regarding outreach opportunities in your local region.

First Name *

Last Name *

Degrees Held

Check all that apply.

B.A.

B.S.

M.A.

M.S.

Ed.M.

M.Phil.

Ph.D.

M.D.

Other:

Email Address *

Please enter your preferred email.

University/Insitutional *

Please indicate your university or institutional affiliation(s).

Home Address *

Street Address 2 (optional)

City

State *

ZIP *

Please enter your postal code.

Phone

Please enter your preferred phone number, starting with your area code (xxx) xxx-xxxx.

Personal URL

Field(s) of Interest *

What topic(s) are you able to speak about to a café audience?

What is your previous Science Café experience? *

Never done a café before, but would like to.

Have done 1 or 2.

I am a café veteran (more than two).

Other:

How far are you willing to travel to speak at a café? *

0-10 miles

10-50 miles

50+ miles

By checking this box, I agree that all personal information provided by me in this form may be used in connection with WGBH's educational outreach efforts as provided above and any other permitted uses as stated in the privacy policy and terms of use for the www.ScienceCafes.org site. *

I agree to the terms above.

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