Speakers Inquiry Form

Speakers Inquiry Form
Thank you in advance for taking the time to tell me about your event.

Our Team will get back to you shortly with the next step.

Please complete the form below by choosing appropriate boxes of interest to you and your organization.
What type of speaking are you interested in?

Keynote - full dayKeynote - multiple daysMastermind - half day/eveningMastermind - multiple daysRetreat SpeakerShare my Story Raising 2 Kids with Juvenile Type One DiabetesCareer DayCollege Special EventParticipate as part of an Expert PanelMaster of Ceremonies - emcee your eventHost/Co-host your eventAward PresenterSpeaker at your Product Launch (endorsement)Interview Chikeitha - Radio, Television, Podcast, Summit, Other (one time interview or a series)Be Interviewed by ChikeithaA Guest Appearance at your Event
About Your Organization
Name of Organization
Contact Person

First NameLast Name
Website Address
Industry or Profession
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Name

First NameLast Name
Phone Number

Area CodePhone Number
Event Date

MonthDayYear
Date
Event Time

:HourMinutesAM/PM Option
What is the Theme/Topic of your Event?
Event's Title and Type of Event
Address of Venue

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated number of attendees?
Please provide a link to your event’s website (alternatively please attach a draft agenda / programme)
Is your event sponsored? If so, please provide details
Self Empowerment

InspirationalMotivationalEmpowermentSpiritual Message
Essentials in Your Organization

Balancing Life and WorkConflict ResolutionCommunication Skills
Family/Relationships

Parenting Skills and SupportCouples and Marital ProblemsDomestic ViolenceCaring for the sick (Children, Spouse, Parents)
Mental Health/Bariatrics/Trauma

Depression and Anxiety and "Mental Health"Anger ManagementGrief and LossObeseity and Trauma/Bariatrics
What do you want your audience to take away and really get out of this event? This helps me to customize my presentation for your event to meet your goals and objectives.
What is the average revenue of your audience members?

$50,000 - $75,000 per year$76,000 - $100,000 per year$101,000 - $150,000 per year$151,000 - $250,000 per year$251,000 - $500,000 per yearOver $500,000 per year
What is your budget? (including travel & accommodations)
Is there anything else you wish to share with us about your event that you think we should know?
Should be Empty: