Workshop Booking and Contracting Form - Renee Roy Hill Today's DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232024Workshop Partner Full Name 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) Three Part Treatment Plan for OPT (Level 1 requirement) OPT: Assessment and Program Plan Development (Level 1 requirement) Motor Speech Disorders: Diagnosis and Treatment Eating and Swallowing: A Global Approach to Feeding Level 3 (Note: there is an addendum for this course and will be sent after this agreement is signed) Level 4 (Note: there is an addendum for this course and will be sent after this agreement is signed) 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." Renee Roy Hill = $3750 per day (TWO DAY WORKSHOP) Renee Roy Hill = $3750 Eating Drinking Swallowing Day One ONLY Renee Roy Hill = $2500 per day ( THREE DAY WORKSHOP) What format is this workshop(Required) Virtual/Streaming Live/In-Person If this workshop is virtual, will TalkTools or Workshop Partner provide the virtual meeting platform (i.e., Zoom) TalkTools will provide the virtual meeting platform Workshop Partner 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 What timezone My timezone US Eastern timezone IN-PERSON: Workshop Venue Name and Address VIRTUAL OR IN-PERSON: Point of Contact (POC) during the workshop(Required)VIRTUAL OR IN-PERSON: first name, last name VIRTUAL OR IN-PERSON: POC email(Required) Estimated Number of Participants(Required)Total Honorarium/Speaker Fee for this workshopDeposit AmountDeposit is equal to 25% of the total speaker fee/honorarium for Instructor. Will you need to purchase practicum (hands-on learning supplies) for this workshop(Required) No -- Workshop Partner has the supplies and will assemble the practicum Yes -- Workshop Partner needs to order practicum kits Practicum/Hands-On Learning Supplies(Required)PLEASE REVIEW THE PRACTICUM LIST FOR THIS WORKSHOP - https://talktools.com/pages/live-workshop-practicum I have reviewed the practicum list I agree to provide practicum for each workshop participant Select PRACTICUM SKU for this Workshop [3801] Three Part Treatment for OPT (Oral Placement Therapy [3803] OPT: Assessment and Program Plan Development [3808] Is it CAS? DIfferential Diagnosis and Treatment [3815] Taking Your Client with Autism from Non-Vocal to Verbal [3816] Level 3 (included in the workshop costs) [3816] Level 4 (included in the workshop costs) Other (this is an placeholder for the purposes of estimating workshop costs) [2515] Eating Swallowing Select PRACTICUM PRICE for this Workshopif "other," only enter dollar amount, not workshop name. Ex., enter "$5" Three Part Treatment Plan for OPT $5 per participant OPT: Assessment and Program Plan Development $10 per participant Is it CAS? Differential Diagnosis and Treatment $25 per participant Eating Swallowing: A Global Approach $15 per participants Taking Your Client with Autism from Non-Vocal to Verbal $5 per participant (Level Three - included in the workshop costs) = $0 (Level Four - included in the workshop costs) = $0 Other Estimated Practicum CostsInstructor Travel Terms Unless other terms have been agreed upon, Workshop Partner agrees that TalkTools arrange and pay for airfare based on air travel estimates Workshop Partner submits in this form. TalkTools will invoice Workshop Partner for airfare TalkTools purchases for this workshop, as part of the final invoice (due to TalkTools within 30 days of the workshop dates) During the Instructor's stay for this Workshop, Workshop Partner agrees to pay and arrange for hotel accommodations, meals and transportation at reasonable rates Estimated Air TravelAdditional Information Estimated Total Workshop Costshonorarium/speaker fee+estimated practicum if purchasing+any other required kits+estimated air travel if workshop is in-person
