Organization/Host Name
(Required)
Organization Website
(Optional)
Contact Person’s Name
(Required)
Contact Email Address
(Required)
Phone Number
(Required)
Social Media Links (Instagram, Facebook, etc.)
(Optional)
Name of the Event
(Required)
Kindly share a brief description of your event, including its main goals and what you hope attendees or viewers will gain from the experience.
Event Type
(Select all that apply – Required)
Keynote
Panel Discussion
Workshop
Conference
Health Fair
Festival
Community Event
Podcast
Radio Interview
Television Interview
Corporate Office Appearance
Zoom Interview
Educational/School Appearance
Church Appearance
Other
Event Format
(Required)
In-Person
Virtual
Hybrid
Is this event public or private?
(Required)
Public (open to all)
Private (invite only)
Event Address
(If in-person)
Event Start and End Time
(Required)
What time would you like Dr. Levi to be present or speaking?
(Required)
Is this your organization’s first time hosting this event?
Yes
No
Not sure
If this is a recurring event, please share a link to past event photos, branding, or marketing materials.
(Optional)
Expected Audience Size
(Required)
Who is your expected audience (community, faith-based, corporate, youth, women’s health, etc.)?
(Required)
Do you already have a specific topic you would like Dr. Levi to focus on?
Is this a panel discussion? If so, please provide the anticipated number of panelists, their focus areas, and the name of the moderator.
Is the event free or ticketed/paid?
(Required)
Free to the public
Paid/Ticketed
Internal/Private access only
Not Sure
Other
Will the event be video recorded?
Yes, and we can share a copy with Dr. Levi
Yes, but we cannot share a copy
Yes, and we can send edited clips of Dr. Levi to her
Not Sure
No
Will there be a professional photographer?
Yes, and we can share select photos with Dr. Levi
Yes, but we cannot share
Not Sure
No
If no photographer/videographer is present, can Dr. Levi bring her own media team?
Yes
Yes, but we require a copy
Not Sure
No
Are there any restrictions on using images, video, or audio from your event in Dr. Levi’s promotional materials?
No
Yes and will explain later
Not Sure
Are you offering any of the following for this appearance?
(Required)
Free appearance (no payment)
Honorarium
Request for Dr. Levi’s full speaking fee
Not Sure
If applicable, will your organization cover travel and other expenses?
Airfare
Hotel
Car service or local transportation
Not applicable
Food (at event)
Additional information or notes you would like to share with us:
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