Speaker Request Form
Thank you for your interest in inviting Chantal Blake to speak at your event.Please complete the form below with as much detail as possible so we can determine the best way to collaborate. You’ll receive a response within 3 business days after submission.
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Name
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First Name
Last Name
Organization
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Email
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example@example.com
Nature of Speaker Invitation
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Keynote Address
Panel Discussion
Interactive Workshop
Podcast or Video Interview
Book Reading and Signing
Fireside Chat or Q&A
Other
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What is the intention for your proposed event?
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Who is the primary audience for this event? (e.g. teens, parents, educators, health professionals, general public, religious/spiritual leaders, etc.)
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How did you hear about Chantal?
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What specific topics would you like Chantal to speak on?
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Womb Wellness and Cyclical Living
Cultivating Fertility Through Cycle Literacy
Honoring the Womb in Islam
Reclaiming Body Literacy for Women
Prophetic Period Positivity
Perimenopause and Menopause: Navigating Sacred Transitions
Menstrual Cycle in Business Leadership and Entrepreneurship
Other
What is the proposed date(s) of the event?
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What is the expected attendance of the event?
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Will the event be free or ticketed?
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Yes
No
Unsure
What is the total duration of expected participation? (e.g., 90-minute keynote, 3 hours including Q&A, full-day attendance, 3-day retreat presence, etc.)
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Are there any additional activities you expect Chantal to attend beyond speaking? (e.g. breakout sessions, ceremonies, meet & greet, pre-event calls, rehearsals, tech checks, etc.)
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Will your event be held online or in-person?
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Online
In-Person
Where is your event located?
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Will your organization be able to cover travel expenses for Chantal and one travel companion?
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Yes
No
Unsure
Will your organization be able to provide private accommodations and meals for Chantal and one travel companion?
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Yes
No
Unsure
Will your organization be able to provide private ground transportation between the point of arrival/departure, accommodation and event space?
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Yes
No
Unsure
Will other speakers or guests be featured at this event? If so, please list them.
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Will the session be recorded? If yes, how will it be used/distributed?
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How do you plan to share this event with your audience? Are there any co-promotion opportunities you’d like to explore with Chantal?
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If you want to provide books at your event, how many copies of Chantal’s book, Peaceful Periods: Holistic Womb Care for Teens, would you like to order?
If you are not interested in providing books for this event, will Chantal have your support in selling her books at this event?
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Yes
No
What is your proposed honorarium or fee for Chantal’s participation?
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What else would you like to share about this proposed event?
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