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Affiliate - PAGE Speakers Bureau Reimbursement Form
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* Indicates required question
Name of Speaker
*
Your answer
Speaker Address for Reimbursement
*
Your answer
Affiliate Location for Presentation
*
Bensalem PAGE
Bethel Park PAGE
Downingtown PAGE
Lancaster PAGE
Lower Merion PAGE
Mifflin Associates for Gifted Students (MAGS)
North Allegheny PAGE
North Penn PAGE
North West PAGE
Northampton PAGE
Norwin PAGE
Pennsbury PAGE
Pine Richland PAGE
Salisbury PAGE
Upper Moreland PAGE
Wilson PAGE
York PAGE
Other:
Name of Speaker
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Gerald Aungst
Barbara Briggs
Maggie Broderick, Ph.D.
Cheree Charmello
Amy Davis
Linda Deal
Kimm Doughtery
Kali Fedor
Katie Leach
Jim LoGuidice
David Mason
Franny McAleer
Judith Mosse
Wendy Palese
Gail Post
Cheryle Radcliff
Daniel Rossi-Keen
Ron Schmiedel
Ann Lupkowski-Shoplik
Mary Ann Swiatek, Ph.D.
Marilyn Thomas
Kelly Wetherhold
Matthew Zakreski
Name of Presentation
*
Your answer
Date of Presentation
*
MM
/
DD
/
YYYY
Please Rate the Presenter
*
Excellent
Very Good
Good
Poor
Ease of scheduling
Communication prior to presentation
Effectiveness of Presentation
Presentation topic and content was as described
Likelihood of inviting the speaker for another session
Overall rating
Excellent
Very Good
Good
Poor
Ease of scheduling
Communication prior to presentation
Effectiveness of Presentation
Presentation topic and content was as described
Likelihood of inviting the speaker for another session
Overall rating
Why did you select this speaker?
*
Your answer
Any Additional Comments
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