Tiana S. Clark - Speaker Request Form
Name
*
First Name
Last Name
Your Email Address:
*
example@example.com
Organization or Company Name
*
Event Name
*
Website
if applicable
Venue Location or Virtual?
*
e.g. Hotel, XXXX Street, Brooklyn, NY (if not virtual)
Event Date
*
/
Month
/
Day
Year
Event Time
*
Hours Minutes Minutes
AM
PM
AM/PM Option
What time would you like Mrs. Clark to begin? Please include the time zone. Mrs. Clark is based in Central time (CT).
*
Is this part of a larger event? Is this part of a series or conference?
Yes
No
Other
What is the objective of this speaking engagement? What would you like the audience to walk away with?
*
How much time is allotted for the presentation?
*
Will there be additional time for Q&A?
*
If so, how much time?
What role would you like Mrs. Clark to play?
*
Keynote Speaker
Panel Moderator
Panel Participant
Workshop Leader
Award Presenter
Interview (or Fireside Chat)
Multi-Media Guest (e.g. podcast, video)
Other
Who will be in your audience?
*
eg. students, executives, all levels
How many attendees are expected?
*
Are there are accommodations for your audience that we should be aware of?
e.g. visual or hearing impairment
What will be the layout of the room?
Theater
Roundtable or Pods
Classroom
U-Shaped (or Large Circle)
Studio
Virtual
Other
Where will Mrs. Clark be presenting from?
e.g. on-stage podium, standing in front of room, Zoom
What is the expected look and feel for this portion of the event?
How will the room look? Are tables assigned? Will attendees be joining directly after lunch?
What is the attire for the event?
Event Media
What audio accommodations will be provided? Do you require any special equipment for virtual settings? Will the speaker use a lapel or hand-held microphone? Will the speaker share the stage with ASL interpreters?
*
Will there be audio/visual capability for projecting content?
*
Yes
No
Will a media team be present?
*
Yes
No
Will the event be recorded?
*
Yes
No
If the event is recorded, how will the recording be used or shared?
*
Speaker Accommodation
Who will be Mrs. Clark's point of contact on the day of the event? Include name, email, and contact number.
What is your speaker budget for this event?
*
Will Mrs. Clark need to travel to attend this event? She is based in the Chicago area.
*
Yes
No
Other
Will your team cover the cost of travel?
Yes
No
Other
What other details are available for any needed travel? When should Mrs. Clark arrive & depart? Is there a hotel room block assigned to this event? Will the timing of your event allow Mrs. Clark to arrive on the same day? What is the closest airport to your event?
Where will Mrs. Clark be met on arrival? Are there any security instructions we should be aware of Where will Mrs. Clark park? Will Mrs. Clark sit with the audience or wait backstage before speaking?
Are there any notable invitations or guests we should be aware of?
e.g. confirmed company executive or public figures
What other information about this event would you like us to know?
If Mrs. Clark is unavailable, would you like recommendations for alternative speakers?
Yes
No
If so, what important factors should we keep in mind while brainstorming alternative speakers?
How did you connect with Mrs. Clark?
Submit
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