Pre-Program Questionnaire
Name of Organization
Main Contact
First Name
Last Name
Cell Number of Main Contact
-
Area Code
Phone Number
E-mail
example@example.com
Address of Event
Name of Venue
Street Address
City
State / Province
Postal / Zip Code
Date of Program
-
Month
-
Day
Year
Date
Start Time of Program. If Adrienne is providing more than one program please enter the start time of the FIRST program. (*Please note: Adrienne's keynotes have a 60 minute runtime unless other arrangements have been made)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Where will Adrienne be delivering her program?
Auditorium
Gymnasium
Other
How many students will be in attendance?
If you have invited other schools to attend the program please let us which additional schools will be in attendance:
In a few sentences please describe the “personality” of the audience:
Are there any student body celebrations or concerns Adrienne should be aware of such as a recent sports championship, recent school award, recent suicide, high pregnancy rate, drug use, sexting, hazing, etc.:
Who is the head counselor at your organization?
First Name
Last Name
Contact info for the counselor
example@example.com
Cell phone number for the counselor
-
Area Code
Phone Number
Would your organization like to purchase any of Adrienne's books for the attendees or library?
yes
no
If yes, how many?
Would your organization like Adrienne to have books available for purchase?
yes
no
Would your organization like a press release about Adrienne’s visit (for use on your website, blog, social media announcements, etc.)?
yes
no
Where should the press release be sent?
example@example.com
Are you willing to appear in an informal video to provide a recommendation and/or testimonial should you like Adrienne?
yes
no
Do you have any questions or further comments for Adrienne?
It is not uncommon teens want to visit with Adrienne after her program. We ask that your organization have a representative with Adrienne until she leaves the building. Who will that representative be? Please list their name, email, cell, and role within your organization.
Yo Adrienne! We are excited for your visit! (Send)
Should be Empty: