The WELL Speaking Engagement Request Form
Use this form to submit a speaking engagement request. Complete all fields using the exact labels and options from the source document.
Organizer / Contact Information
Organization / Church / Business Name
*
Contact Person
*
First Name
Middle Name
Last Name
Title / Position
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Website / Social Media
Event Details
Event Name
*
Event Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Speaker Arrival / Call Time
*
Hour Minutes
AM
PM
AM/PM Option
Event Location (City, State)
*
Venue / Facility Name
Event Format
*
In Person
Virtual
Hybrid
Expected Number of Attendees
Primary Audience / Age Group
Will the event be open to the public?
*
Yes
No
Engagement Scope
Type of Engagement
*
Keynote
Workshop
Panel
Retreat
Conference
Other
Type of Engagement - Other (please specify)
Requested Topic / Theme
*
Attendee Takeaways
*
Requested Speaking Length
*
15–30 min
30–45 min
45–60 min
60–90 min
Other
Requested Speaking Length - Other (please specify)
Will Q&A be included?
Yes
No
Will books, resources, or merchandise be permitted for sale?
Yes
No
Please describe the event and its purpose
*
Other speakers, panelists, or special guests
Dress Code / Attire Expectations
Special Program Requirements or Expectations
Travel, Logistics, and Budget
Will travel be required?
*
Yes
No
If travel is required, who will arrange transportation?
Host
Speaker
To Be Discussed
Will lodging be required?
*
Yes
No
Will meals / ground transportation be provided?
Yes
No
To Be Discussed
Parking / Venue Access Information
Is a speaker honorarium / speaking fee available?
Yes
No
Budget to Be Discussed
Available budget or honorarium range
Additional requirements, reimbursements, or contractual terms
Permissions, Links, and Submission Details
May the event be photographed or recorded?
*
Yes
No
May portions of the presentation be used for promotional purposes?
*
Yes
No
Event flyer, promotional materials, or website link
Additional information about the event or speaking request
Name of Person Submitting Request
*
First Name
Middle Name
Last Name
Date Submitted
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: