BOOKING REQUEST FORM
Dr. Brandynicole will use the skills of engagement, empowerment and education to get your audience excited about the work ahead. Please complete this booking request form and a member of her team will be in touch within 24-72 business hours.
POINT OF CONTACT (POC) INFORMATION
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Best Mode of Contact
*
Email
Phone (Text)
Phone (Call)
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ORGANIZATION INFORMATION
Organization Name
*
Organization Website
*
Type of Organization
*
Non-Profit Organization
College/University
Small Business
Child Welfare Agency
Mental Health Agency
Other
If other, please describe.
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EVENT INFORMATION
What is the event's topic or theme?
*
Event Venue
*
Online
In-Person
If in-person, please provide the venue information below.
*
Venue
Street Address Line
City
State / Province
Postal / Zip Code
Full Event Duration (1 day, 2 days, etc.)
*
Event Date(s)
*
Event Time(s)
*
What is the fee to attend your event ?
*
How many are expected to attend your event?
*
Who are the event participants (age range; profession(s); etc.)?
*
Is this a public or private event?
*
Public
Private
Will the event be recorded?
*
Yes, and available to participants only.
Yes, and available to the public.
No
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SESSION INFORMATION
Which are you requesting of Dr. Brandynicole?
*
Keynote Address
Workshop (60 min.)
Consultation
Facilitator
Panelist
Media Appearance (TV, Podcast, Radio)
Emcee
The Complete Compassion Workshop
Other
Do you have a speaking/training topic in mind? If so, please share more below.
*
If other, please describe.
How long would like you Dr. Brandynicole to present/participate?
*
Will Dr. Brandynicole's session be recorded?
*
Yes, and available to participants only.
Yes, and available to the public.
No
How did you hear about Dr. Brandynicole?
*
Website
Youtube
Word of Mouth
Social Media
Other
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What additional information would you like Dr. Brandynicole to know about your event, your participants, or her session?
I consent to Dr. Brandynicole marketing her participation on social media platforms.
*
Yes
No
Please verify that you are not a robot.
*
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