Form
Let's Glow 2026 - Speaker Information Request
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Tell us about your story and the magic you have to share!
Please upload a high-quality headshot for promotional use.
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Proposed title of your talk/workshop?
Short description of your talk/workshop:
ROLE & STAGE TIME - I agree to participate as a Speaker and receive up to fifty (50) minutes of stage time, as scheduled by the Host. How much time would you prefer to be on the stage?
15 minutes
30 minutes
45 minutes
Other
How would you like to be introduced on the stage?
What social media/contact links do you want us to use to promote you prior to and during the event?
Where have you taken the stage in the past? Or future?
How many "followers" do you have on social platforms?
Looking for a general idea of reach and influence.
SPEAKER OFFER & COMPENSATION - Speaker understands that this is a non-paid speaking opportunity. Speaker receives a twenty percent (20%) commission on ticket sales generated through their referrals. The speaker is responsible for registering for and properly using their affiliate link. Additional inclusions include one (1) complimentary vendor booth, professional photography, access to event photos, full event admission, and one (1) complimentary General Admission ticket.
Yes
No
TRAVEL & ACCOMMODATIONS - Speaker understands that travel, lodging, and transportation are not provided by the Host.
Yes
No
PROMOTION REQUIREMENTS - Speaker agrees to actively promote the Event across social media platforms at least four (4) times and to participate in at least one (1) live or recorded promotional session with Tanya Chaney prior to the Event.
Yes
No
PROFESSIONAL CONDUCT & NON-DISPARAGEMENT - Speaker agrees to conduct themselves with professionalism, integrity, inclusivity, and respect throughout all Event-related interactions.
Yes
No
MEDIA & INTELLECTUAL PROPERTY - Speaker retains ownership of original content and grants Host a perpetual, royalty-free license to record, photograph, and use the Speaker’s name, likeness, voice, and presentation for marketing, promotional, educational, and archival purposes.
Yes
No
REQUIRED ATTENDANCE - Speaker agrees to attend the entire Let's Gow Embodied Leadership Experience from Sept 11-13, 2026.
Yes
No
Speaker agrees to available for VIP Prelude on Friday, September 10th from 6-8pm?
Yes
No
Speaker agrees to be available for VIP Dinner on Saturday, September 11th at 5/6pm?
Yes
No
CANCELLATION - Speaker understands that failure to attend required components of the Event may result in forfeiture of participation and associated Speaker benefits.
Yes
No
LIABILITY & ASSUMPTION OF RISK - Speaker voluntarily assumes all risks associated with participation in the Event and related travel.
Yes
No
GOVERNING LAW - Speaker understands that this Agreement shall be governed by and construed in accordance with the laws of the State of Pennsylvania
Yes
No
ENTIRE AGREEMENT This Agreement constitutes the entire understanding between the parties and supersedes all prior agreements or discussions. Any amendments must be made in writing and signed by both parties. Signed copy from Host constitutes approval - You will be approved upon review.
Yes
No
Signature
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