Speaking Services Request Form
Please fill in the form below.
Company Name
*
Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Location (City, State/Province, Country):
*
E-mail
*
Program Interest(s):
*
Do you have any preferred presenters (pending availability)?:
*
Virginia Spielmann
STAR staff
Doesn't matter
Do you have a preference for format?:
*
In-Person (you provide venue)
Livestream (via zoom)
Online (pre-recorded, on-demand content)
Hybrid (having both online and livestream sections)
Doesn't matter
Specific Dates/Timeframe you are seeking to schedule
*
Please list any and all types of Audiences, e.g. OTs, SLPs, PTs, parents, educators, etc.:
*
Estimated number of attendees (including from your own organization):
*
AOTA CEUs may be provided for an additional cost of $100 per course. *International Organizations: For a small fee, STAR Institute can support with obtaining professional development units from your local professional organization.
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Yes
No
Other
Do you have or have access to an established mailing list to utilize in marketing this program locally?
*
Yes
No
N/A (will not be marketing outside my own organization)
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