Speakers Inquiry Form
Thank you in advance for taking the time to tell me about your event. Our Public Relations Team will get back to you shortly with the next step. Please complete the form below by choosing appropriate boxes of interest to you and your organization.
What type of speaking are you interested in?
Keynote
Workshop - half day/fullday
Retreat Speaker
Participate as part of an Expert Panel
Master of Ceremonies - emcee your event
Host/Co-host your event
Award Presenter
Interview Dr. Taniqua - Radio, Television, Podcast, Summit, Other (one time interview or a series)
A Guest Appearance at your Event
About Your Organization
Name of Organization
Contact Person
First Name
Last Name
Website Address
Industry or Profession
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Event Date
-
Month
-
Day
Year
Date
Event Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What is the Theme/Topic of your Event?
Event's Title and Type of Event
Address of Venue
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Estimated number of attendees?
Please provide a link to your event’s website (alternatively please attach a draft agenda / programme)
Is your event sponsored? If so, please provide details
Women in Midlife
Burnout Recovery in Midlife
Perimenopausal Transition
Other
Continuing Medical Education
Mitigation Bias in Delivery of Midlife Healthcare
Other
What do you want your audience to take away and really get out of this event? This helps me to customize my presentation for your event to meet your goals and objectives.
What is your budget? (including travel & accommodations)
Is there anything else you wish to share with us about your event that you think we should know?
Submit
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