First Name:
Last Name:
Age(if 21 or under):
Address:
Address:
City:
State:
Zip:
Telephone:
Fax:
Email:
Member Agency:

Adult Sponsor Information (If under 21):
First Name:
Last Name:
Agency/Organization:
Telephone:
Email:

This presentation is being submitted by a(an):
Youth         Adult
Presentation Title:
(short and specific)
Under which workshop session would you place your presentation topic?
Presentation Description:
 (50 words or less)
Your description may be edited
for use in the Summit Program.
Learning Objectives:

1.
2.
3.

How is your presentation focues specifically on the theme of the Summit?
(25 words or less)
To what extent and how does your presentation involve youth, if at all?
Learning Methods:
(select all that apply)

Lecture
Interactive
Facilitated Discussion
Experimental

 

 Panel Discussion
Audio-Visual Presentation
Other:
Specific sector audience for whom the presentation is relevant:
All audiences
Educators
Youth (12-15)
Youth (16-19)
All attending youth
 Policy Makers
Media
Health Professionals
Parents
All attending adults
Level of audience knowledge for which your presentation would be most appropriate:
Beginning
Intermediate
Advanced
All Levels


List 2 References
Reference individuals who can attest to your expertise
relating to the session/presentation proposal and your
ability to present or facilitate in front of a diverse group):
Name
Email or Phone
 
Name
Email or Phone
   
Provide a brief biography of qualifications, relevant experience, and familiarity with hip-hop/youth popular culture:
(50 words or less)
Adults, please indicate if you would prefer to be on a panel or secure your own workshop:

Panel
Speaker
No preference