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

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?

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?

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

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?

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)?

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

How will the event be promoted to attract attendees?

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

Will there be other speakers or presenters at the event?

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

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Will the event be recorded?

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

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.