Gravity Form to e-signature-International Workshops (Ellis) Today's Date04123456789101112191234567891011121314151617181920212223242526272829303120242025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Workshop Partner Full Name(Required) First Last Workshop Partner Organizaton(Required) Workshop Partner email(Required) Workshop Partner Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Workshop Course(Required) 3-Part Treatment Plan for OPT (Oral Placement Therapy) (Level 1 course requirement) OPT: Assessment and Program Plan Development (Level 1 course requirement) Eating Drinking Swallowing: A Global Approach (Level 2 course elective) Pediatric and Adult Dysphagia: What's Your "Swallowology" Workshop Instructor(Required)NOTE: Eating Drinking Swallowing: A Global Approach is co-presented by 2 Instructors, Renee Roy Hill and Colette Ellis, so TWO CONTRACTS are needed (one for each Instructor). When entering the number of days, enter "1." Colette Ellis $2500 Eating Drinking Swallowing Day Two ONLY Colette Ellis $2500 per day for two day workshop Collete Ellis $1750 for three day workshop What format is this workshop(Required) Virtual/Streaming (TalkTools will provide the virtual meeting platform) Virtual/Streaming (Workshop Partner will provide the virtual meeting platform) Live/In-Person Start Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202520242023End Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202520242023Total Number of Days(Required)Start Time(Required)each day Hours : Minutes AM PM AM/PM End Time(Required)each day Hours : Minutes AM PM AM/PM Are these times in YOUR timezone?(Required) The times are in my time zone The times are US Eastern (UTC-4) Workshop Venuename of workshop location, street, city Workshop Point of Contact (POC) during workshop(Required)VIRTUAL OR IN-PERSON: first name, last name Workshop POC email(Required) Estimated Number of Participants(Required)Total Honorarium/Instructor Compensation for this workshopDeposit AmountDeposit is equal to 25% of the total instructor compensation/honorarium for InstructorWill you need to purchase practicum (hands-on learning supplies) for this workshop(Required) Yes -- Workshop Partner will order practicum for each participant No -- Workshop Partner has the supplies and will assemble the practicum for each participant Practicum/Hands-On Learning Supplies List(Required)PLEASE REVIEW THE PRACTICUM LIST FOR THIS WORKSHOP - https://talktools.com/pages/live-workshop-practicum Workshop Partner has reviewed the practicum list Workshop Partner agrees to provide practicum for each participant Select the PRACTICUM SKU for this workshop if you are purchasing [3801] 3-Part Treatment Plan for OPT [3803] OPT: Assessment and Program Plan Development [2515] Eating Drinking Swallowing: A Global Approach [3820] Pediatric and Adult Dysphagia: What's Your Swallowology Select the PRACTICUM PRICE this workshop if you are purchasing $5 Three-Part Treatment Plan for OPT $5 OPT Assessment and Program Plan Development $15 Eating and Swallowing: Global Approach $15 Pediatric and Adult Dysphagia What is Your Swallowology Estimated Practicum Costsauto-calculatedInstructor Travel Terms Workshop Partner agrees that TalkTools will arrange airfare for Instructor based on estimates Workshop Partner has provided in this Agreement During the Instructor's stay for this Workshop, Workshop Partner agrees to pay and arrange for hotel accommodations, meals and transportation at reasonable rates TalkTools will bill Workshop Partner for these costs, as part of the final invoice (due to TalkTools within 10 days of the workshop dates) Estimated Air TravelEstimated Total Workshop Costsauto-calculated (honorarium/speaker fee+estimated practicum if purchasing+estimated air travel if workshop is in-person)
