Authors on the Road

FOR OFFICE USE ONLY:
Grant Number:_____________________ Check Received:____________________
_Check Number:____________________ Date Closed:______________________
Stipend:__________________________ Travel:____________________________
TOTAL:___________________________ Date of Event:______________________

Fiscal Year:

1. Sponsoring Organization Name: *This question is required.

2. Sponsoring Organization Address: *This question is required.

Address
City
State
Zip

3. Phone: *This question is required.

4. Phone Type: *This question is required.

Home
Work
Cell

5. Project Coordinator Name: *This question is required.

6. Project Coordinator Address: *This question is required.

Address
City
State
Zip

7. Phone: *This question is required.

8. Phone Type: *This question is required.

Home
Work
Cell

9. Email: *This question is required.

10. Email Type: *This question is required.

Home
Work
Cell

11. Name of Requested Presenting Author/Speaker: *This question is required.

12. Grant Amount Requested (up to $500): *This question is required. This question requires a valid currency format.

13. Expected Amount from Other Sources (preference will be given to organizations able to provide additional support): *This question is required. This question requires a valid currency format.

14. Speaker/Discussion Leader Name: *This question is required.

15. Speaker/Discussion Leader Email:

16. Have you confirmed the program, date, time, and location with the presenter? *This question is required.

17. Event Location: *This question is required.

18. Event Location Address: *This question is required.

Address
City
State
Zip

19. Event Date(s): *This question is required.

20. Event Time(s): *This question is required.

21. Estimated Audience Size: *This question is required.

22. Briefly Describe the Program Format (classroom, discussion, auditorium lecture, etc.) and List Grade Level(s) Involved: *This question is required.

23. Publicity Plans: *This question is required.

By signing this form, the coordinator agrees to:

Supervise arrangements - provide necessary A/V equipment - organize transportation for the speaker to and from Deadwood if necessary - supply hotel accommodations (if program falls outside festival dates) - publicize the program - acknowledge funding from SD Humanities Council, an affiliate of the National Endowment for Humanities - complete a final evaluation and cost share form - certify that the sponsoring organization will comply with statutes regarding nondiscrimination.

24. Program Coordinator Electronic Signature: *This question is required.

25. Date (MM/DD/YYYY Format): *This question is required.

Authors on the Road

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