Speaker Request for Power of Choice Mentoring Program
Name
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First Name
Last Name
E-mail
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Phone Number
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-
Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organizational Affiliation
How did you hear about our program?
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Website
Youtube
Word of Mouth
Social Media
Other
Speaking Duration/ ex: 30 minutes, 45 minutes ?
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Suggested dates for your event
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Are these dates flexible?
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What specific topics would you be excited to speak on?
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If you have a blog, website, outside ministry, or business, please share your links here. (This is not a requirement or even necessarily an asset.)
Do you have any criminal convictions anywhere in the United States? (not a disqualifier, but being honest is best)
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Felony
Misdemeanor
NONE
Link to a video of you speaking. (for both speaker and moderator roles)
We require a video for consideration. Even a short 2-minute video works. If your link is to a worship service with multiple people on screen, please give us a time stamp or other indication of who you are. No video link means your application will not be reviewed. Please check the link. If we can’t access your video, we can’t consider you. **If you have spoken for us in the past, we do not need a video.
Video of yourself speaking at an event, ministry, non-profit organization etc.
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Are you a new or returning speaker?
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I am new
I am a returning speaker
Is there anything we missed or anything else you would like to share?
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