Wellness For Life Journey
Speaker Form
Name
First Name
Last Name
Email
example@example.com
Name of Organization:
Venue Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Direct Phone Number
*
Please enter a valid phone number.
Event Description & Goal:
*
Event Date:
Event Start & End Time:
Earliest Setup Time:
Name of Event:
Venue Name, Phone Number and Address: (if different than above)
Event Type:
*
Virtual
In-Person
Hybrid
Expected Number of Attendees:
*
Event Ticket Price (if Applicable):
How would you like for us to serve your audience?
*
Wellness For Life Journey Caregiver Wellness Workshop
Panelist
Keynote Speaker
Workshop/Breakout Session
Special Music/Vocal Artistry
Wellness Retreat
Wellness Fair
Outdoor Wellness Experience / Tailgate
Other
Audience Profile: (check all that apply)
*
Women Family Caregivers
Community Members
Corporate Staff / Professionals
Primary Wellness Interests: ___________________
May we offer attendees a complimentary wellness check or resource and collect their contact information for follow-up?
*
Yes
No
Desired Outcomes for This Session: Example: Increase energy, reduce stress, improve focus, team building, morale boost, etc.
*
Primary Wellness Focus for This Session/ What Core Topic Should We Center This Experience Around?
*
Desire Length of Workshop/Session/Experience: (required)
*
Budget for Guest Facilitator/Wellness Session:Please indicate your allocated budget for this session so we can customize accordingly.
Submit
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