Contact Information Contact Name: * Chapter/Section: * Role within IDSA: * Email: * Phone: * What are you planning: * Chapter Activity (a sole activity) Section Activity (a sole activity) Connected Activity (a collaboration event with a Chapter / Section / Education / Association / Other) Chapter / Section Purchase Other Activity Description Collaborator: * Note: If this is NOT a Connected Activity please enter "NONE". For Connected Activities please specify the Chapter, Section, Educational Institution, Association or Other Entity you collaborated with. Describe Activity/Purchase/Other: * (Note: form submission should be a minimum of 2 weeks prior to activity to ensure proper approval and promotion. Activities requiring the assistance of IDSA National Staff (caterer, venue, contracts) should be submitted a minimum of 6 weeks prior to activity.) Date: * Year Year20132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Start Time: Hour hour123456789101112 : Minute minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm End Time: Hour hour123456789101112 : Minute minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Venue: Title: * Description: * Topic/Content: Proposed Speakers/Participants: Will content be captured for future use?: How will IDSA be represented at this event?: * PowerPoint/Video Poster Brochures/flyers/applications Other signage IDSA spiel Estimated Attendance: * Estimated Expenses: * Estimated Revenue: * Estimated Sponsorship Revenue: * How will sponsorship be collected?: IDSA will invoice. Money will be collected on-site by section/chapter. Is online registration required?: Will any contracts need to be negotiated and signed for this activity?: (Note: Only an authorized IDSA staff member is allowed to sign a contract on behalf of IDSA.) Please describe any additional IDSA support you require? : (conference calls, webinar set-up, etc.) Will additional insurance be required for this activity?: Expense-Revenue Breakdown: Additional Comments: CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.