Workshop Booking and Contracting Form -- Monica Purdy Today's Date Month Day Year Workshop Partner Name(Required) First Last Workshop Partner Organization(Required) Workshop Partner Email(Required) Workshop Partner Address(Required) Street Address Address Line 2 City 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) OPT: Three Part Treatment Plan (Level 1) OPT: Assessment Plan Development (Level 1) Superpowers of the Sensory System Level 3 (Addendum for this course will be sent after the Agreement is signed) Level 4 (Addendum for this course will be sent after the Agreement is signed) Feeding Foundations Other Workshop Instructor(Required) Monica Purdy $3000 per day for two day workshop Monica Purdy $2500 per day for two day workshop Monica Purdy $2000 per day for three day workshop (same number of hours as two day) Monica Purdy (copresenting) $1500 per day What format is this workshop(Required) Virtual/Streaming Live/In-Person If this workshop is virtual, who is providing the virtual streaming platform Workshop Partner will provide the virtual meeting platform (ex., Zoom) TalkTools will provide the virtual meeting platform Start Date(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232024End Date(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232024Total 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) Yes, these times are my timezone No, these times are US Eastern timezone IN-PERSON: Workshop Venuename of workshop location, street, city VIRTUAL OR IN-PERSON: Point of Contact (POC) during workshop(Required)first name, last name Estimated Number of Participants(Required)Total Honorarium/Speaker Fee for this workshopDeposit AmountDeposit is equal to 25% of the total speaker fee/honorarium for InstructorWill you need to purchase Participant Practice Kits (practicum) 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 Participant Practice Kits (practicum) 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 Participant Practice Kits (practicum) SKU for this workshop [3801] Three Part Treatment Plan for OPT [3803] OPT: Assessment and Program Plan Development [3816] Level 3 (included in the workshop costs) [3818] Level 4 (included in the workshop costs) [3824] Superpowers of the Sensory System [3831] Kaleidoscope Model for Feeding Other Select the Participant Practice Kits (practicum) PRICE for this workshop Three Part Treatment Plan for OPT $5 per participant OPT: Assessment and Program Plan Development $10 per participant Superpowers of the Sensory System $5 participant Kaleidoscope Model for Feeding $5 per participant Other $5 per participant (this is a placeholder for the purposes of estimating workshop costs) Level 3 Level 4 Estimated Practicum CostsInstructor Travel Terms Unless other terms are agreed upon, Workshop Partner agrees that TalkTools will arrange cost-effective airfare for Instructor During the Instructor's stay for this Workshop, Workshop Partner agrees to pay and arrange for accommodations, meals and transportation TalkTools will invoice Workshop Partner for any travel costs incurred, as part of the final invoice (due to TalkTools within 30 days of the invoice date) Estimated Total Workshop Costshonorarium/speaker fee+estimated practicum if purchasing (travel will not be included in the calculation)
