BHA Speaker Request Form
Thank you for contacting Barnes Health Affiliates, LLC for your speaker request. Kindly, please complete this speaker request form and you will receive a response within 72 hours. -Dr. Kamila Barnes, DNP, FNP-C www.bhapro.com
Salutation
*
Ms.
Mrs.
Mr.
Mx.
Dr.
Other
Name of Requestor
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Event Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Host Organization Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Host Website or Social Media Page
*
Event Type
*
In-Person
Virtual
Hybrid (with speaker in-person)
Hybrid (with speaker on virtual)
Anticipated START Time of Event
*
Hour Minutes
AM
PM
AM/PM Option
Anticipated END Time of Event
*
Hour Minutes
AM
PM
AM/PM Option
Title of Event
*
Briefly describe the purpose of this event.
*
0/150
Speaker Requested Role
*
Keynote
Panelist
Lecturer
Workshop/Training
Pre-Recorded Remarks
Honorary Host
Brief Remarks
Will the Press be invited?
*
Yes
No
Proposed Compensation:
*
Paid
Paid + Travel/Lodging Expenses
Honorarium
Unpaid/Voluntary
Other
Additional comments (OPTIONAL):
0/150
Submit
Should be Empty: