Alexis Alsup- Speaker Event/ Engagement Request Form

Alexis Alsup- Speaker Event/ Engagement Request Form

Thank you for requesting Alexis Alsup. She is a passionate advocate for maternal health equity, a seasoned birth doula, and a dedicated student midwife. She brings her expertise, lived experiences, and deep commitment to fostering empowerment and education in maternal health to every presentation. We look forward to collaborating with you!
Please complete the form below and send the following items to Alexis.Midwifery@gmail.com:
- Orginal Invitation Letter
- Agenda ( Draft or Final)
- Other relevant materials
If you have any questions or concerns, please contact us via email listed above. Upon receipt of this form along with your supporting documentation, your infromation will be reviewed and an email response will be sent.
Email
example@example.com
Event Name
Event/ Organization Website:
Also, acceptable: IG or Social Media Platform
Event Start Date

MonthDayYear
Date
Event End Date

MonthDayYear
Date
Event Time Zone
Event Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Event (e.g. Meeting, Interview, Conference, Town Hall): Please list topic, event theme and other details.
Requested Participation Arrival Time (Day of Event):
Requested Participation Date(s):
Speaker Request
Name of Requester

First NameLast Name
Organization/Company
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reason for chosen Alexis as your speaker choice?
Budget for Speaker?
What is the form of payment for event speakers (if applicable)?
Event Audience
Expected Audience Size
Audience Demographics
Audience Seating Style (please check the one that applies):
Logistics
Speaker Session Format
Presentation Set up? Select all that apply.
Are you requesting slides?
When will the slides need to be emailed prior to presentation (if applicable)?
Please list the exact time frame or number of minutes the speaker will be expected to prepare for(Example: 45 min lecture)
Time allotted for speaking engagement:

Hour Minutes
Will the meeting be recorded? (Please check all that apply):
Do you wish to have a technology run-through?
Date/Time of tech run-through?
Please note that Alexis Alsup will only attend tech run throughs if she has no experionce with the platform. Alexis Alsup can ONLY accommodate tech checks if the date/time are listed on the form.
Are there Equipment/AV Requirements? If yes, please provide below:
Do you wish to have a planning meeting?
Is parking available? If yes, please provide details:
Additional Information
Will there be a pre/post event? If yes, please provide details:
What is the Event Attire?
Is a conflict-of-interest form required?
Will any media be present? (please check all that apply and include pertinent details and if they are local/national, if applicable):
If your organization has special requirements for travel, please list them below:
Other Requests or Comments
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Alexis Alsup- Speaker Event/ Engagement Request Form

Speaker Request

Event Audience

Logistics

Additional Information

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