---

SPEAKER INFORMATION

Today's Date (mm-dd-yyyy)

*First Name

*Last Name

*Email Address

*Re-enter email address

*Street Address

*City

*State

- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip Code

*Phone Number (best way to contact)

*Title/Position (in the lacrosse industry)

*Organization

*US Lacrosse Member Number (Forgot your member number? Click here to retrieve it! Do not have a member number or its expired? Please click here to sign-up or renew your membership.)

*Level of Officiating (Select the highest level held)

- Select- Youth(15 and Under) High School College Post College International Other

*Have you previously presented at the US Lacrosse National Convention?

- Select - Yes No

If yes, which year(s)?

Shirt Size (Women's Polo's are cut a little small/short)

- Select - Men's Small Men's Medium Men's Large Men's XLarge Men's XXLarge Men's XXXLarge Women's Small Women's Medium Women's Large Women's XLarge Women's XXLarge Women's XXXLarge

*SPEKAER BIO (No more than 500 words)

FACEBOOK Page (Social media is a big part of our Convention marketing plan to promote speakers prior to the Convention)

TWITTER Handle (Social media is a big part of our Convention marketing plan to promote speakers prior to the Convention)

PRESENTATION INFORMATION

*PRESENTATION 1

*Presentation Title

*Topic

- Select - Mechanics Game Management Rules Points of Emphasis Other

*Target Audience (To select multiple target audiences, hold down the CONTROL (CTRL) key and click on the selected audiences)

- Select - UMPIRE Youth/Local UMPIRE HS/District UMPIRE NCAA UMPIRE International ALL

*Key Words/Skills Learned/Brief Description (Please List 3-5 keywords/skills/concepts that will be taught in this session).

*Presentation Format

- Select - Classroom Panel Field Demo

(Please note that if you select "demonstration" this does not guarantee a Live Field spot. You might be asked to present your demonstration in a classroom setting).

Co-Presenters Please list each co-presenter's name including organziation, email address, and PERCENTAGE OF SPEAKER FEE TO BE SPLIT.

PRESENTATION 2

Presentation Title

Topic

- Select - Mechanics Game Management Rules Points of Emphasis Other

Target Audience (To select multiple target audiences, hold down the CONTROL (CTRL) key and click on the selected audiences)

- Select - UMPIRE Youth/Local UMPIRE HS/District UMPIRE NCAA UMPIRE International ALL

*Key Words/Skills Learned/Brief Description (Please List 3-5 keywords/skills/concepts that will be taught in this session).

Presentation Format

- Select - Classroom Panel Live Field Demonstration

(Please note that if you select "demonstration" this does not guarantee a Live Field spot. You might be asked to present your demonstration in a classroom setting).

Co-Presenters Please list each co-presenter's name including organziation, email address, and PERCENTAGE OF SPEAKER FEE TO BE SPLIT.

PRESENTATION 3

Presentation Title

Topic

- Select - Mechanics Game Management Rules Points of Emphasis Other

Target Audience (To select multiple target audiences, hold down the CONTROL (CTRL) key and click on the selected audiences)

- Select - UMPIRE Youth/Local UMPIRE HS/District UMPIRE NCAA UMPIRE International ALL

*Key Words/Skills Learned/Brief Description (Please List 3-5 keywords/skills/concepts that will be taught in this session).

Presentation Format

- Select - Classroom Panel Live Field Demonstration

(Please note that if you select "demonstration" this does not guarantee a Live Field spot. You might be asked to present your demonstration in a classroom setting).

Co-Presenters Please list each co-presenter's name including organziation, email address, and PERCENTAGE OF SPEAKER FEE TO BE SPLIT.

REFERENCES

*1st Reference:

*Reference Name

*Reference Email Address

*Reference Phone Number

2nd Reference (Optional):

Reference Name

Reference Email Address

Reference Phone Number

I UNDERSTAND THAT THE CONTENT OF MY PRESENTATION WILL BECOME PROPERTY OF THE 2015 US LACROSSE NATIONAL CONVENTION AND WILL BE RECORDED AND MADE AVAILABLE AS AN EDUCATIONAL RESOURCE.

I UNDERSTAND THAT I WILL RECEIVE AN HONORARIUM BASED ON THE SIZE OF MY PRESENTATION AT THE CONVENTION. I ALSO UNDERSTAND AND AGREE THAT I AM RESPONSIBLE FOR PAYING ALL TRAVEL-RELATED EXPENSES ASSOCIATED WITH THE CONVENTION (includes airfare, meals and hotel).

I UNDERSTAND THAT IF CHOSEN TO PRESENT AT THE 2015 NATIONAL CONVENTION, THAT MY PRESENTATION MUST UPHOLD THE SPIRIT OF THE GAME AND TEACH THE RULES AS INTENDED TO BE TAUGHT. PRESENTATIONS SHOULD NOT INCLUDE ANYTHING THAT MIGHT BE DEEMED CHEATING OR PLAYING OUTSIDE THE CURRENT RULES OF THE GAME.

Check here if you would also be interested in presenting information during web seminars as part of the US Lacrosse Coaching Education Program continuing education initiative.

Additional Comments