Distinguished Speaker Request Form

Please use this form to request a speaker for an event at your institution. You have the option of requesting a standard visit or a funded visit. Host institutions are expected to cover all expenses for standard visits. NAGT will help cover the speaker's travel expenses for approved funded visits.

Departments/institutions who receive funding agree to the following:

Before the visit, the Department will fill out a brief questionnaire describing the curriculum and styles of teaching currently used, and what the Department hopes to achieve by the visit.
Before the visit, the Department will make arrangements to invite neighboring schools to the Speaker's visit
The Department will cover the speaker's local food, accommodation and travel costs, the costs to photocopy workshop materials, and the cost of a substitute, if the Speaker is a high school teacher.
Following the visit, the Department will submit an evaluation of the visit.
The Department will submit a report to the Speaker Coordinator six months after the visit to report on changes stimulated by the Speaker's visit.

Note: You need to complete this form in one sitting. After finishing, please press the Submit button at the bottom of the page. If you leave this page before hitting Submit, any information you have entered will be lost.
Name of Contact Person

Institution

Mailing Address

Phone Number

FAX Number

Email Address

Please select your first choice speaker.

Please select your second choice speaker.

Please select your third choice speaker.

Expected audiences (check all that apply)
Faculty teaching primarily undergraduate classes
Faculty teaching both undergraduate & graduate classes
Graduate students interested in academic careers
Undergraduate students interested in K-12 education
K-12 teachers

Please describe what your Department/Institution would hope to achieve by the visit

Please describe your scheduling preferences or constraints for hosting a speaker

Speaker FundingFunded Visits: Funding to cover the cost of a Distinguished Speaker's travel to and from a host institution is available on a first-come- first-served basis. Responses to the competition will be communicated within two weeks. If the application is funded, we will work with you to schedule a Speaker's visit. Your department will be expected to pay for a Speaker's local expenses, costs for duplicating a reasonable volume of workshop materials, and the cost of hiring a substitute, if the speaker is a pre-college teacher.

Standard Visits: If you do not wish to apply for funding to cover a Distinguished Speaker's travel, fill out the application in order to schedule a visit. A host department is expected to pay for a Speaker's travel and local expenses, expenses for duplicating a reasonable volume of workshop materials, and the cost of hiring a substitute, if the speaker is a pre-college teacher.

Is your department interested in applying for funding to host a speaker?

Yes
No

Has your department been previously funded for an NAGT Distinguished Speaker visit? If so, who and when?

By applying for funding the Department/Institution agrees to the following:

Before the visit, the Department will fill out a brief questionnaire describing the curriculum and styles of teaching currently used, and what the Department hopes to achieve by the visit.
Before the visit, the Department will make arrangements to invite neighboring schools to the Speaker's visit
The Department will cover the speaker's local food, accommodation and travel costs, the costs to photocopy workshop materials, and the cost of a substitute, if the Speaker is a high school teacher.
Following the visit, the Department will submit an evaluation of the visit
The Department will submit a report to the Speaker Coordinator six months after the visit to report on changes stimulated by the Speaker's visit.

Our Department accepts the responsibilities which accompany requesting a speaker from the program.

Name of Department Chair

Email Address of Department Chair

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