Form

2012 IAEA Electronic Proposal Submission Form
Complete this proposal form and click the SUBMIT button by March 15, 2012

You may submit more than one proposal, but only submit once per proposal (do not submit both electronically and via mail). You must be a current member of IAEA to submit your proposal. Visit http://ilaea.org/membership to become a member or renew your membership.

CONTACT PERSON

Vicki Kanik

Home Phone: (630/553-6759)

Email: vkanik2@aol.com

Please notify Vicki if ANY of this information changes after you have submitted your proposal.

Visit http://ilaea.org/conferences for detailed information about the proposal submission process.
SUBMISSION DEADLINE: MARCH 15, 2012
Presentation Title*
Lead Presenter*
First Name Last Name
Co-Presenters
Presentation Format*

Workshop (classroom with hands-on format) Workshop (classroom with mainly demonstration format) Session
Presentation Time Block*

45 Minutes 105 Minutes 165 Minutes (Daytime Workshop) 90 Minutes (Friday Night Workshop - limited openings)
Audience Level*

Elementary Middle School High School Higher Ed All Levels
State Goals

25A 25B 26A 26B 27A 27B
Workshop and Presentation Session Set Up (check all that apply)
NOTE: IAEA does not provide projectors or computers for presentations or workshops

Water Accessibility Needed Student Assistant Needed Will Bring AV Equipment for Workshop / Session Internet Access Needed (Presenter must contact the hotel)
(Presenter must contact the hotel in advance if their session or workshop is scheduled in the hotel to make internet arrangements. Internet access for off-site presentations will be arranged through the conference coordinators).
Workshop Participant Limit

15 20 25
Workshop Fee

No Yes
IAEA does NOT reimburse presenters for presentation expenses unless the presenter has assigned a fee to participate in the workshop or session and the presenter has submitted documented receipts to IAEA by the published deadline.
If you selected yes under "Workshop Fee" indicate the fee amount
You will be contacted about specific requirements for your session or workshop after your proposal has been received and accepted for the conference. To help us plan the schedule, please answer these questions:
Are you presenting with someone else in another session?

No Yes
If you selected yes, please list the individual(s) name
(to make sure we do not schedule your presentations at the same time)
Are you willing to present your session or workshop a second time?

No Yes
Are you submitting more than one proposal?

No Yes
Are you planning to submit student work for consideration for the student art show?
(for scheduling purposes - the show will take place Saturday morning)

No Yes
Presentation Description
Describe your presentation or workshop in 35 words or less*

(see 2011 conference Mosaic issue for examples of descriptions) 0/35
Lead Presenter Contact Information

Mailing Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

School / Institution Name
(school where teaching or attending if a student)
School / Institution Level

Elementary Middle School High School Higher Ed Museum Ed Community Program / Non-Profit

School Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number
- Area Code Phone Number
Teaching Level / Job Alike Category
(if you are a college student list your degree program)
(for lead presenter)
Cell Phone Number
- Area Code Phone Number
Work Phone Number
- Area Code Phone Number
E-mail*
Summer / Alternate Email Address
SUBMISSION DEADLINE: MARCH 15, 2012
You must be a current member of IAEA for the 2011-2012 membership year to submit a proposal. All proposals will be returned to submitters who are not current members. If your proposal is accepted, you must also renew your IAEA membership for 2012-2013 prior to the conference and register for the conference

Review Your Answers and Click "Submit" to Complete the Proposal.

You will automatically receive a copy of this proposal via your email address, however you may also PRINT this form if you would like a copy of this proposal for your records (NOTE: This will print 5 pages. The email summary is only 2 pages and can also be printed).
Should be Empty:

2012 IAEA Electronic Proposal Submission Form

SUBMISSION DEADLINE: MARCH 15, 2012

You will be contacted about specific requirements for your session or workshop after your proposal has been received and accepted for the conference. To help us plan the schedule, please answer these questions:

Presentation Description

Lead Presenter Contact Information

SUBMISSION DEADLINE: MARCH 15, 2012