Facilitator Information Form

Name *

First

Last

Email *

Phone *

Address

City, State Zip

Are you willing to share your session's PPT/Handouts with participants? *

Are you willing to share your contact information with other Forum facilitators? *

What would you propose as a two-sentence description of your presentation to include in the Forum Program Booklet?

In consideration of the opportunity to appear on an audio/videotape depicting various aspects of the presentations and activities of the 2024 USA/Canada Lions Leadership Forum, the undersigned hereby waives any and all rights and interests in said audio/videotapes, relinquishing said rights to the 2024 USA/Canada Lions Leadership Forum, including, but not limited to, the right to receive any and all proceeds derived from the sale of said tapes for educational and promotional purposes.

ELECTRONIC SIGNATURE: *

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IMPORTANT NOTICE: Typing your name in the box above will constitute your electronic signature.

Date / Time *

Date

Time