Event Request Form [soliloquy id=”191″] Event Request Form Please complete this form so we can support you and your event! Event ContactPlease enter your name, email, and phone number.Name*Email*Phone*Event DetailsTitle*Start Date*End Date*Time*Short Description*Workshop description should be concise and easy to readFormatCheck all that apply* In-Person Livestream Webinar (all online) - Synchronous Webinar (all online) - Asynchronous Will the event be recorded?*(If yes, speaker must complete the Speaker Agreement Form)Select from drop down optionsYesNoTarget Audience*Check all that apply Graduate Students Professionals SSW Faculty / Staff Broader UNC Community Community-at-Large Other Other Audience*Please SpecifyLocation(s)* Tate-Turner-Kuralt Building On Campus Off Campus Not confirmed - need assistance Tate-Turner-Kuralt*Check all that apply Auditorium Room 500 Room 300 Room 227 Room 135 Room 113/114 (special permission required) JIF 1st Floor SIE Lab 1st Floor Lobby On Campus*Fill in name of location with addressOff Campus*Fill in name of location with addressFood*Select from drop down optionsProvidedOn their ownNot necessary (event is short)Need assistance with ordering foodEco-friendliness*Select from drop down optionsLandfill eventGreen eventNeed assistance with compostingWill there be a fee to attend?* Yes No How much?*Are there groups of people who can attend for free?* Yes No What groups can attend for free?*Select all that apply Current Students Field Instructors Other Are there scholarships available?* Yes No Do you have a registration link?* Yes No Please share your registration link:*Do you need assistance with registration?* Yes No Speaker InformationSpeaker name*Speaker Biosketch*Will the speaker receive and honorarium?* Yes No How much?*NOTE: If an honorarium is provided directly to the speaker, he/she/they must complete an Independent Contractor form and supply a W9 at least 30 days prior to event. If speaker is paid through their business then he/she/they must supply a W9 at least 14 days prior to event.Continuing EducationPlease select all that apply* I would like to provide contact hours (open to any attendee regardless of background – contact hours meet requirements for LCSWs in North Carolina only) I would like to provide Association of Social Work Education (ASWE) credits for social workers I would like to provide National Board for Certified Counselors credits I would like to provide CE for other professions or boards I am not providing any formal training recognition Please specify*Evaluation*How will people complete the evaluation? Paper form distributed at the event Electronic form distributed during the meeting Emailed evaluation after the event Not doing an evaluation I need help putting together an appropriate evaluation Certificates of CompletionHow will people receive their certificates Hand out at event On-line, prompted by emailed evaluation I need help with certificates Other LogisticsWill you need parking for the speakers?* Yes No How many passes will be needed?*(fill in number)Will any guests require disability parking?* Yes No Not sure Refund Policy* No refund at all No refund after a certain date Refund regardless of when cancellation happens Not applicable May vary Refund cut-off date*Inclement Weather* Will reschedule Will happen regardless (live stream or webinars) Will cancel Unsure AV Requirements* Internet connection Video(s) as part of presentation Livestreaming Table / Chairs White board / flip chart Microphones Laptop Mac adaptor Other None Quantity*Please specify quantity for each selected itemSpecify other requests*Food* Provided On their own Not necessary (event is short) Need assistance with ordering food Δ Key Contact: Sarah Verbiest Last Updated: December 12, 2018
