youth infusion event registration form
please email completed form to firstname.lastname@example.org
Today’s Date: Organization Name Staff Contact Name
Email Address Phone Fax
Date of Event Event Title Description of Event (Purpose, Goals, Other Speakers) Where Will the Event be Held? Event Logistics: Access to LCD Projector?
Access to Sound System?
Access to Photocopier?
Audience: Youth Adults Youth/Adults Expected Number: _______Youth ________ Adults
Familiarity with Experts Received Previous Event Subject Training Limited Knowledge
Matter: Completely New Subject
Experts Received Previous
Training Limited Knowledge
Completely New Subject
Keynote General Session Type of
Workshop/Breakout Retreat Presentation
Requested: Meeting Facilitation Training
Audience: Youth Adults Youth/Adults
Expected Number: ________Youth ________ Adults
What are your goals for the presentation?
**If you would like Youth Infusion to conduct more than one presentation at your event, please fill out a separate form for each
(excluding the general organizational information that you already completed)
Program Materials (Do you need Youth Infusion to submit materials prior to the event?) Date Needed By: ______________________
Presentation Description Speaker Bios Handouts
Youth Infusion Materials (Would you like Youth Infusion to develop customized curriculums, handouts, etc.?) Date Needed By: __________________
Pre-Conference Packets for Participants Conference Packets Brochures Website Content Curriculums Take Home PowerPoint Pre-Event Media Training (Would you like Youth Infusion to provide media training to staff/youth leaders prior to the event?)
Anything Else Youth Infusion Should Know?
Youth Infusion provides its services to organizations free of charge, provided all travel expenses and supplies are taken care of by the organization. Youth Infusion typically sends two staff members to each event. Supply expenses are generally under $250.00
Should we arrange transportation independently, and submit reimbursements?
Should we arrange transportation through your organization?
Additional Reimbursement Procedures We Should Follow: