ECA Presenter/Exhibitor Request Form


If you have any questions about this form, please email info@earthquakecountry.org.

To request a presenter or information table for your event, please complete this form with as much detail as possible. We understand that some aspects of your event may still be developing, so “TBD” is OK for now if something is unknown. Fields marked with ” * ” are required.

Your Contact Information
Name:*
ZIP Code:
Organization:
Phone number:*
Alternate phone number:
E-mail address:*
Event Details (as much as you know now)
Specific date requested:
OR     Date flexibility?
Please give us a general idea, such as “My group meets on the 2nd Tuesdays of each month, and the months of April, August and November are currently available”.
Event location*
Please provide the physical address if possible, but if details are still pending please provide a city and/or zip code
Event start time:
Event end time:
Expected audience: General Audience
Government agency staff
Elected officials
Businesses
Non-profits

Community group
Educators
Youth (elementary grades)
Youth (secondary grades)
Seniors
People with disabilities
Primary language spoken by attendees:
Other language(s) spoken by attendees:
Accommodations for People with Disabilities:
We anticipate people with these abilities to attend: Mobility disabilities
Visual disabilities
Deaf/Hard of hearing
Cognitive/Intellectual disabilities
Other
Have you arranged for or will you provide (upon request) interpreting or captioning services? Yes   No
Does the site have accessible parking, access throughout the space, and accessible restrooms? Yes   No
Will there be other accommodations?
(Please explain)
Presenter Details (if applicable)
Presentation start time:
Desired presentation length:
Does that include Q&A? Yes   No
Presentation style: PowerPoint/video/etc. comments only either
Setting: indoors   outdoors
Expected audience size:
Will there be more than one presenter? Yes   No

If yes, please explain above.
Special interest or emphasis desired?
Please tell us if your group has a special interest, such as pet preparedness, the science of earthquakes, or other topics.
Is there a specific presenter you prefer?
Exhibitor Details (if applicable)
Set up time:
Setting: indoors   outdoors
Expected number of attendees:
Expected number of exhibitors:
Any special/unique aspects to the event?
Equipment Provided (for presenters, exhibitors, or both)
Please indicate what equipment you are able to supply, if any, and other details about the venue. Projection Screen
Projector
Flatscreen TV
Presentation Computer
HDMI cable
Remote control
Fixed microphone
Handheld corded microphone
Wireless handheld microphone
Wireless lapel mic or over-ear mic
Connection for computer audio
Extension Cords
Raised stage or platform
Lectern
Table for presenter
Table for handouts
Chairs for exhibitors
Pop-up tent
Outdoor power access
Cart/dolly available
VIP or easy-access parking
Please provide any additional information or submit questions and comments here.