Department of Education
Kevin Huffman, Commissioner

Participation Form

To indicate your willingness to participate in the delivery of an Institute please complete the following information.

Name:             _______________________________________

System:           ______________________________________

Phone number:  ______________________________________

Fax number:    _______________________________________

E-mail address:  ______________________________________

I am willing to participate in the CEO program as:

(     ) a group facilitator

(     ) a discussion leader

I am interested in facilitating or leading a discussion during a specific session.  (Please indicate session.) _________________________

Additional Opportunities

I have expertise, interest and/or experience that would enhance the meeting ____________________________________   Institute.                      
date           city          session#

I am willing to participate by:

___________________________________________________________________

___________________________________________________________________

Return to:

Barry Olhausen, Executive Director
Office of Professional Development
710 James Robertson Parkway, 4th Floor
Nashville, TN   37243-0376