Aging While Black Speaker Request Form

Name of Host Organization or Company*

Brief Description of Organization's Mission & Vision*

Contact Person*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date of Event *

Date

Event Title & Theme*

Nature of Event*

In-personVirtual

If in person, Venue Location (city and country)

Expected start and end time of the speaking engagement (including Q&A)*

Brief overview of event's purpose & objectives. *

Expected total number of attendees*

Any available demographic information about the audience *

Are attendees required to pay to attend the event?*

YesNo

If yes, please provide registration fee (write n/a if not applicable)

If there is an admission fee, can we offer a special discount code to our audience?

YesNo

Will the event offer CEUs or any other type of professional credits for attendees?*

YesNo

If yes, please specify the type and amount of CEUs available.*

Please indicate the budget allocated for speaker fees. *

Will you cover travel expenses, including airfare and ground transportation?*

YesNo

What type of accommodation, if needed, will be provided during the speaker's stay?*

Will AV equipment and setup be available at the venue (e.g., projector, microphone, clicker, laptop)?*

YesNo

Will a stage, podium, or lectern be made available?*

YesNo

How will the event be promoted to attract attendees? *

Will we be provided with materials or collateral to promote the event with our network?*

YesNo

Will there be other speakers or presenters at the event?*

YesNo

If available, please provide a tentative schedule of the event.

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Will the event be recorded?*

YesNo

If so, can we obtain a copy of the speaking session?*

YesNo

Are there any other relevant details about the event that you believe we should be aware of?

Thank you for taking the time to answer these questions. Your responses will greatly assist us in evaluating the alignment of your event with our skills, interests, and availability. We look forward to the opportunity to collaborate and inspire your audience.