Application_BlackTie Legacy Engagement Form

BlackTie Legacy Engagement Form
Thank you for your interest in our services. Please fill out the form below to help us understand your personal, professional or community wellness needs. Upon completing the form, you will be directed to discovery call scheduling platform where we will discuss your needs further; this is a requirement. Should you need to make changes to your discovery call, use the reschedule link or email Dr. Jewel at support@jwhitewilliams.com.
Name*

First NameLast Name
Email*
example@example.com
Organization*
Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which audience needs best aligns with to achieve growth in your business/organization?*

Educator WellnessCommunity HealthEntrepreneurial/Leadership WellnessCPR, AED and First Aid Training (AHA)Other
Give more insight about the audience or yourself.*
Which topic aligns with what you want your audience to gain from this service?
*Please visit the speaker/professional development page of www.jwhitewilliams.com to align for clarity.
Select the service that you are requesting.
How long are you seeking for this session to be?*

One Hour90 MinutesHalf Day (3-4 hours)Full Day (6-8 hours)Other
What is your organizations estimated budget for this service. *
Please note that leaving this question unanswered may affect the next steps in the process.
Please feel free to share any additional details about your needs that may not have been covered in this questionnaire. (optional)
Add any additional documents that will help us understand your business or company's needs for health and wellness.(optional)

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