Scheduling Request form for Dr. Katie Jenner V2

Group or individuals making request*
Your Full Name*

First NameLast Name
Job Title*
Phone Number*
E-mail*

Confirmation Emailexample@example.com
I would like to:*

Schedule a meeting with Dr. Katie JennerRequest Dr. Jenner’s attendance at an event
Purpose of Meeting (Please describe the topic you would like to discuss.)*
Who is your audience?*

TeachersParentsStudentsOther
Audience size*
What are you requesting (remarks in-person, virtual remarks, panel discussion, pre-recorded greeting)?*
Meeting Time Frame (Please Select One)*

I would like to request a specific time frame.At Dr. Jenner’s earliest convenience.
At what specific time would you like to meet?*
Ex: I would like to meet the week of Dec.12.
Others in attendance*
Location of Meeting*
Please enter full address, or indicate that you can come to Dr. Jenner’s office.
Please specify parking, building entrance and room number details if applicable
I would like Dr. Jenner to be a*

GuestHonoreeKeynote SpeakerSpeaker/PanelistOther
Date and Time of Event*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Event*

Venu Name

Street Address

CityState

Zip Code
Description of Event, including Dr. Jenner’s role/purpose.*
Attach the agenda here.

Cancelof
Audience*
Please include a description of attendees, who Dr. Jenner will be addressing and the expected number of attendees.
Will press/media be present at this event? If so, in what capacity?*
Ex: School tour from 10:30-11:00 Speaking from 11:00am-11:15 Lunch from 11:30-12:30.
Please specify parking, building entrance and room number details.*
Ex: Park in the west parking lot, enter through door 3, proceed to main office and prep in room A7.
Other Details
Please verify that you are human*
Should be Empty: