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Date

Organization

Phone(Required)

Email(Required)

Website

Title of Program/Presentation(Required)

Description of Program(Required)

Targeted Age Group(Required)

Maximum # of participants(Required)

Length of program(Required)

Cost(Required)

professional fee, material costs, etc.

Have you presented this program elsewhere? Please describe and include contacts for reference.

Do you have upcoming programs scheduled in the region already? Please list venues and dates.

What networking resources and methods do you have to help promote this program?

Not required, but this certainly helps to get the word out.

Equipment or supplies provided by the presenter(Required)

Equipment or supplies requested at performance site(Required)

Comments

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