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*
Community organizations- Groups focused on maternal health advocacy, education, and equity.Students-Midwifery, nursing, and public health students interested in maternal health and birthwork.General public- Community events, conferences, or forums promoting education and awareness around maternal health and empowerment.Healthcare Providers: Hospitals, clinics, and professionals aiming to improve maternal health outcomes and integrate doula/midwifery support.Expectant Parents: Workshops or discussions on birth preparation, postpartum care, and family health.Birth Workers: Doulas, midwives, and other professionals seeking insights on equitable maternal care and professional development.Policy Makers & Advocates: Stakeholders working to address disparities in Black maternal health and improve access to maternal care.Corporate Groups: Companies supporting employee wellness, maternal health initiatives, or DEI programming.
AuditoriumClassroomTheater style round tablesBanquetOther
Logistics
KeynotePanel discussionWorkshopPresenter
Single PodiumTable PodiumStanding on stage without table platformOther
YesNo
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
AudioVideoRemoteBroadcast (pre-recorded or live)WebcastN/A
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:
YesNo
Is parking available? If yes, please provide details:*
Additional Information
Will there be a pre/post event? If yes, please provide details:*
CasualBusiness CasualBusiness
YesNo
RadioTVPrint NewspaperOnline BlogN/A
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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