Coordinator

The coordinator is the point of contact for the ACA Professional Development Specialist. If the coordinator listed will also be a moderator and/or speaker for this workshop proposal submission, please complete the required moderator/speaker field with your complete contact information.

Title: Esq. Mr. Mrs. Ms. Degree: Have you passed ACA's Certification Examination (which one)? CCE (Certified Corrections Executive) CCM (Certified Corrections Manager) CCS (Certified Corrections Supervisor) CCO (Certified Corrections Officer) Coordinator First Name: Coordinator Last Name: Job Title: Agency/Organization: Division/Department/Office: Facility/Program:

Address City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Work Phone: Cellular Phone: Fax: Email:

Refrences

Refrence 1 First Name: Last Name: Job Title: Agency/Org: Phone Number: E-Mail:

Refrence 2 First Name: Last Name: Job Title: Agency/Org: Phone Number: E-Mail:

Please complete this form with current & accurate information. Please make it your responsibility to call each moderator, speaker and evaluator to verify all information -- it will appear in the official Conference Program Book. Thanks for your cooperation.

Moderator The moderator is responsible for introducing the speaker(s), distributing and collecting the Attendee Evaluation Form, and completing the Evaluation Feedback Form. **Please note that all workshops must have at least (1) moderator and (1) speaker as a part of their workshop presentation.
Title: Esq. Mr. Mrs. Ms. Degree: Have you passed ACA's Certification Examination (which one)? CCE (Certified Corrections Executive) CCM (Certified Corrections Manager) CCS (Certified Corrections Supervisor) CCO (Certified Corrections Officer) First Name: Last Name: Job Title: Agency/Organization: Division/Department/Office: Facility/Program:		Address City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Work Phone: Cellular Phone: Fax: Email:
Speaker #1
Title: Esq. Mr. Mrs. Ms. Degree: Have you passed ACA's Certification Examination (which one)? CCE (Certified Corrections Executive) CCM (Certified Corrections Manager) CCS (Certified Corrections Supervisor) CCO (Certified Corrections Officer) First Name: Last Name: Job Title: Agency/Organization: Division/Department/Office: Facility/Program:		Address City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Work Phone: Cellular Phone: Fax: Email:
Speaker #2
Title: Esq. Mr. Mrs. Ms. Degree: Have you passed ACA's Certification Examination (which one)? CCE (Certified Corrections Executive) CCM (Certified Corrections Manager) CCS (Certified Corrections Supervisor) CCO (Certified Corrections Officer) First Name: Last Name: Job Title: Agency/Organization: Division/Department/Office: Facility/Program:		Address City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Work Phone: Cellular Phone: Fax: Email:
Speaker #3
Title: Esq. Mr. Mrs. Ms. Degree: Have you passed ACA's Certification Examination (which one)? CCE (Certified Corrections Executive) CCM (Certified Corrections Manager) CCS (Certified Corrections Supervisor) CCO (Certified Corrections Officer) First Name: Last Name: Job Title: Agency/Organization: Division/Department/Office: Facility/Program:		Address City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Work Phone: Cellular Phone: Fax: Email:
Speaker #4
Title: Esq. Mr. Mrs. Ms. Degree: Have you passed ACA's Certification Examination (which one)? CCE (Certified Corrections Executive) CCM (Certified Corrections Manager) CCS (Certified Corrections Supervisor) CCO (Certified Corrections Officer) First Name: Last Name: Job Title: Agency/Organization: Division/Department/Office: Facility/Program:		Address City State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Work Phone: Cellular Phone: Fax: Email:
All presentation rooms come equipped with a PC Projector, Projector Screen, Podium with (1) Microphone, AV Outlets and Surround Sound Audio, If you would like to request other AV functions to supplement your presentation, please contact the Professional Development Specialist directly at daryas@aca.org. Also please note that LAPTOPS ARE NOT PROVIDED.
American Correctional Association Program Committee Speaker/Participant Registration Policy If a speaker, who is a nonmember, is not employed in the field of corrections and is attending the Conference only for his/her presentation and will not be visiting the Exhibit Hall, he/she can apply for a waiver of the registration fee. If approved, a badge allowing the speaker access to his/her session will be prepared for him/her and will be available at the conference registration area, if the fee is waived. If a speaker, who is a nonmember, works directly within the field of corrections or if he/she is out of the field, however, earns a living via the field (i.e., vendor, professor, consultant), he/she shall pay the registration fee regardless of the number of sessions that he/she will be presenting at or attending. This policy also applies to retired correctional professionals and foreign participants working in the field. (One day registration is available at less cost than full registration.) Speakers who represent private vendors or companies shall not use the speaker role as a forum to market specific products or services, but rather must present a generic presentation on the topic. Furthermore, products and services for which the speaker represents shall not be named or referred to by name in any presentation. Attendees with questions about such products or services shall be informed to see an individual at the conclusion of the presentation and/or program. Attendees may also be directed to visit various booths in the Exhibit Hall. All ACA members who are speakers will pay a registration fee. (As approved by ACA's Board of Governors on August 4, 2002.)