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PSAHPERD INNOVATION & TECHNOLOGY PRESENTER FORM
Thursday, June 15, 2017
PATTAN Harrisburg

Presenter’s Response Form due by March 10, 2017

Title of Session
Your answer
Brief Description for Program & Brochure
25 words or less
Your answer
Speaker Information
Summary of qualifications and one paragraph biography of speaker(s)
Your answer
PA ACADEMIC STANDARD GRADE BAND
Choose the grade level band for the standards you are selecting. Check all that apply
Required
PA State Academic Standards Addressed
Check all that apply if applicable
Domain of Danielson Framework
Check all that apply
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SPEAKER #1 INFORMATION
For each speaker, include the following information
Is the speaker # 1 a member?
Speaker # 1 Name & Title
e.g. M.Ed., Ed, etc
Your answer
Speaker # 1 School / Agency
Your answer
Speaker # 1 Mailing Address
Street Address, City, State, Zip
Your answer
Speaker # 1 Phone
(111) 555-1212
Your answer
Speaker # 1 Email
Your answer
SPEAKER #2 INFORMATION
For each speaker, include the following information
Is the speaker # 2 a member?
Speaker # 2 Name & Title
e.g. M.Ed., Ed., etc.
Your answer
Speaker # 2 School / Agency
Your answer
Speaker # 2 Mailing Address
Street Address, City, State, Zip
Your answer
Speaker # 2 Phone
(111) 555-1212
Your answer
Speaker # 2 Email
Your answer
How does your seminar demonstrate innovation and / or technology in teaching?
Your answer
What skills and ideas will participants be able to do during and after your seminar?
Please list in bullet-point format
Your answer
Special Instructions for Participants
Please indicate if participants in your session should bring any of the following to help them learn better. CHECK ALL THAT APPLY.
Other Special Instructions for Participants
Your answer
MODE OF PRESENTATION
Check all that apply
Required
AUDIO-VISUAL NEEDS
Please make a brief statement about your AV needs. Each room will have projectors, smart-boards, clickers, DVD players, and wireless internet. If you need anything additional to that, please discuss that here.
Your answer
Questions:
Contact Todd Bedard: tbedard2@gmail.com
Contact Jessica Peconi-Cook: peconicooks@gmail.com
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