Dementia Workshop & Speaking Engagement Request Form

Dementia Workshop & Speaking Engagement Request Form

Dementia Up Close and Personal with Ellen Samson
Thank you for your interest in hosting Dementia Up Close and Personal with Ellen Samson.

This form helps us understand your organization, audience, venue, goals, and preferred schedule so we can recommend the best workshop or speaking format for your facility, care home, organization, or event.

After you submit this form, our team will review your request and contact you with the next steps.
1. Contact Person
Full Name

First NameLast Name
Position / Title
Example: Administrator, Activity Director, Marketing Director, Social Worker, Owner, Executive Director
Organization / Facility Name
Type of Organization
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Way to Contact You
2. Event Interest
What are you interested in?
Preferred Format
Preferred Length
3. Audience
Who will attend?
Type a question
What is the audience’s current level of dementia knowledge?
4. Goals and Expectations
What do you want your audience to gain from this session?
What type of dementia talk or workshop are you interested in? Choose all that apply:
Are there specific topics you want Ellen to cover?
What tone do you prefer for the session?
5. Event Details
Do you already have a proposed date?
Preferred Date

MonthDayYear
Date
Preferred Time
Alternate Date or Time
Event Location
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you already have a venue?
Venue Setup Available
6. Technical Needs
Will there be AV equipment available?
Can you provide a screen or projector for slides?
Will the event be recorded?
Will photos or videos be taken for social media?
Do you need promotional materials from us?
7. Budget and Sponsorship
Is there a budget for this event?
Estimated Budget Range
Would you like to discuss sponsorship options?
8. Additional Details
How did you hear about Ellen Samson / Dementia Up Close and Personal?
Please share anything else we should know about your event, audience, or goals.
9. Consent and Submission
I understand that submitting this form does not confirm the event date. A team member will contact me to review the request, availability, format, and next steps.
Should be Empty:

Dementia Workshop & Speaking Engagement Request Form

1. Contact Person

2. Event Interest

3. Audience

4. Goals and Expectations

5. Event Details

6. Technical Needs

7. Budget and Sponsorship

8. Additional Details

9. Consent and Submission