2018 Les Lukert Winter Conference Presentation Proposal Form

Contact Information for Presenter

Name: ______Title:______Agency/Company: ______Address:______City:______State:_____ Zip: ______Phone:______Cell: ______Email address: ______Presentation Information

1. Title of Presentation: ______Please provide a 50 word descriptive overview of your presentation suitable for use in Conference advertising. ______

______

*The NSFSI Conference Planning Committee reserves the right to amend workshop titles & descriptions.

2. Have you ever taught the proposed presentation at another conference? If yes where? ______

3. Please provide contact information from other conferences you have presented at

______

______4. Style of Presentation:  Interactive Lecture Hands On Training

5. Preferred length of presentation:

12 hours (1 co-speaker allowed for classroom and 2 for Hands On Training, contact information,

and bios of both presenters must be included) 8 hours (1 co-speaker allowed; contact information, and bios of both presenters must be included)

4 hours (single speaker)

7-8 hours (single speaker) Friday Pre-Conference Instructor Professional Development Class

7-8 hours (single speaker) Friday Pre-Conference H.O.T. Class

6. Please include your minimum and maximum numbers of students. Minimum_____ Maximum ______

7. Additional Speakers: (Names and Titles please) 1. Name: Title: Email address: 2. Name: Title: Email address:

8. Target Audience: (Please check all that apply)  Instructors/Training Officers   Firefighters  Fire Chiefs   Chief Officer  Other, please list (i.e. Hazmat,

 Company officers Rescue, EMS, etc.) 9. Audio/Visual Equipment: Please check one of the following: (Screens, wireless internet, sound system are provided)  No AV equipment needed I will provide my own AV equipment.

 I will need the following AV equipment provided for me:

 Projector  Name tent style cards

 Flip Chart and Markers  Lectern/podium

 Laptop Computer  Other: speakers / sound

 Lavaliere microphone  Other:

 Other:

10. Biography: Please include a brief 35 word biography in paragraph form for EACH speaker written in third person suitable for use in conference advertising.

 ______

  11. How would you categorize your class (check which apply):  Leadership  HazMat

 Strategy and Tactics  Instructional Methodology  Technical Rescue  EMS for Instructors

 Wildland  Health , Safety and Survival

 EMS for Providers  Other (Explain)______

 ______12. Would you consider doing a keynote speech for the Saturday Evening Leadership Banquet?  If yes, please provide topic and or summary. ______ ______ ______

 Items requested if proposal is accepted for presentation:

- Electronic copy of presentation or handouts - Digital photo of each presenter – must be in jpg format with a minimum 300 dpi quality - A short video describing the presentation to use to promote conference and presentation

  Any questions can be directed to Tim Linke via email at [email protected] 

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