Speaker Request Form
Your Name?
*
First Name
Last Name
Your Contact Email
*
example@example.com
Your Contact Phone Number
Format: (000) 000-0000.
Organization Name
*
Tell us a little bit more about your organization.
*
Organization Website
*
Name of Requested Event or Conference
*
Date of Event
*
/
Month
/
Day
Year
Date
Type of Event
*
In-person
Virtual
If Virtual, what platform?
*
Zoom
Youtube/Facebook Live
Webex
GoToWebinar
Microsoft Teams
GoogleMeets
Other (Share in event description below)
In Person Event Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How will the event be marketed? Is their opportunity for co-branding on all promotional materials (social media, flyers, website etc...)
What is the speaker's focus or topic
Empowerment
Personal Development (Coaching)
Diversity, Equity, Inclusion, Workplace Development
Spiritual
Other *share in event description below
Tell us a little bit more about the event. (Theme(s) and/or Focus of Gathering, length of time for speaker, webinar/logistics are there multiple speakers etc).
Are you looking for a keynote-style talk, a panel discussion, or an interactive workshop? Would you like the session to include Q&A or activities?”
What message or impact are you hoping the speaker will leave with your audience?
Expected Number of Attendees
*
Is the event open to the public, or limited to your organization?
*
Target Audience (check all that apply)
*
Women
Men
Both
Target Audience Age Group (check all that apply)
*
Elementary School Age
High School Age (13-15)
High School Age (16-18)
College Students
Adults 18-25
Adults 25+
Seniors
If Date is flexible, please list a few options.
Do you have a budget for an Honorarium? (This doesn’t rule out your request, but it helps with speaker selection and availability).
*
Yes
No
If in-person event, will Hotel and Travel Expenses be reimbursed?
*
Yes
No
N/A
If in-person, will there be a Resource Table available for books or promotional items?
Yes
No
N/A
Additional Relevant Information or Requests. Will there be audio/visual support for slides, video, or music? If in-person, are there any specific guidelines or dress code for speakers? Do you need any promotional materials or bio details from us for your flyers or social media?
Submit
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