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Request a Speaker for an Event
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Your Organization/ Company Name:
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Your Organization/ Company Address:
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Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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3
Please provide a brief description of the event - include event type (ie: men's breakfast, women's luncheon, school assembly, etc.), event focus/ topic, and any other relevant details.
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4
What is the date of the event?
/
Date
Month
Day
Year
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5
Time of the event:
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6
What is the location of the event?
Please include address and any other relevant details such as building name, room number, etc.
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7
Audience Profile:
Organization
Business
Non-Profit
Church / Faith Community
Students - Elementary
Students - Junior High
Students - High School
Students - College
Other
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8
If "Other," please explain here:
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9
Anticipated Number of Attendees:
Less than 25
25 - 50
50 - 75
75 - 100
100 +
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10
Presentation Type:
Prevention
Training
Crisis
Dinner/ Banquet
Panel
Informational
Other
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11
If "Other" please explain here:
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12
What is the estimated duration of the speaker's presentation?
Less than 30 minutes
30 - 45 minutes
45 - 60 minutes
1 hour +
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13
Who is the preferred speaker?
Please select two-three options to ensure maximum avalability.
Lisa Bownds - CEO/ Founder
Samye Flock - Prevention & Education Director
Leslie Rodriguez - Director of Operations
Robert Fowler - Community Partnership Director
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14
Do you have a specific budget in mind for the speaker at your event?
Yes, I have a budget (please provide the estimated budget range in the next question).
No, I do not have a specific budget.
I am hoping the speaker could participate for free.
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15
If you answered yes, what is your budget?
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16
Are there any specific requirements or preferences for the speaker's background or experience?
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17
If you have a specific topic or focus you would like the presentation to follow, please list it here.
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18
What media equipment will be provided for the speaker?
Microphone - Lapel
Microphone - Handheld
Microphone Stand
Projector
Screen
Podium/ Stand
Computer
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19
What media elements are needed?
PowerPoint
Thumb Drive
SD Card Reader
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20
Would you like us to set up a merchandise table?
YES
NO
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21
Travel and Expenses:
Please select all that your company/ organization will be providing.
Honorarium
Air Fare
Rental Car/ Transportation
Hotel
Meals
None
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22
Travel Expense Agreement
*
This field is required.
By clicking here, you indicate your agreement to reimburse Reflection Ministries for all travel expenses outside of Midland/Odessa, including mileage, airfare, hotel, and car rental.
I agree
I disagree
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23
Is there any additional information you would like to provide about the event?
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24
First name
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25
Last name
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26
Phone number
Area Code
Phone Number
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27
Email
example@example.com
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28
Please verify that you are human
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