Request a Media Visit
First Name
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Last Name
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Email
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Phone Number
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Street Address
Street Address 2
City
State / Province
Zip Code
Country
Emergency Contact Name
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Emergency Contact Phone Number
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Allergies or Restrictions?
Health Concerns / Physical Limitations
Others Attending (if children, include ages)
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Media Outlet Information
Media Outlet(s)
Facebook
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Other
Audience Profile/Reach
Do you plan to post to social media during your visit?
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Coverage Information
Have you visited Butler County?
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Approximately how long ago?
Scope of Story / Anticipated Coverage
On assignment?
Yes
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Assignment - Yes or No, Please Describe
Date of Arrival
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Month
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Day
Year
Date
Estimated Time of Arrival
Date of Departure
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Month
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Day
Year
Date
Estimated Time of Departure
Lodging Needed?
Yes
No
Lodging - Yes or No, Please Describe
Complimentary / Media Rate?
Yes
No
Comp/Media Rate - Yes or No, Please Describe
Assistance with meals?
Transportation assistance?
Requesting an itinerary?
Requesting a guide/escort?
Interview requests
Places you'd like to visit
Interested in destinations nearby (outside Butler County)?
Other interests / requests
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