Dr. Noemi Adame: Speaker, School-Based, or Corporate Consultation Request Form
Thank you for expressing your interest in requesting Dr. Adame's expertise for your event.  Please fill out the form below and someone on our team will follow up with you to schedule a consultation to discuss how we can meet the wellness needs for your school, organization, corporate retreat, or event. 
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Email *
Name *
Email  *
Phone Number *
How would you like to be contacted? *
Name of Organization 
Organization's Website 
How did you hear about Dr. Noemi Adame and/or Culver Pediatrics Center?  Check all that apply.  *
Required
For which Speaking or Consultant Service are you interested in retaining Dr. Adame? Check all that apply.  *
Required
What is the name of the event in which you would like Dr. Adame to speak or consult?
Event website
Event start date
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Event end date
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What time would you like Dr. Adame to speak?
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Is the event  *
Required
Event Location (if in person)
What budget have you allotted for Speaker/Consultation Services for this event, school-based program, or professional development training?

 *
Will the audience earn educational (CME, CNE, CE) credits? *
Do you permit speakers to promote products and services from the stage?  *
Can Dr. Adame/Culver Pediatrics Center take videos and/or potos during the event for use in socials, website, and marketing? 
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Are you able to share videso/photos of  the event for use in Culver Peds socials, website, and marketing? 
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Check the time frame for which you would like to retain Dr. Adame's speaking/consulting services.  *
Required
Who is the audience? Be as specific as possible  (example: elementary school wishing to improve school-based nutrition program; manufacturing corporate executives who want to increase productivity and workforce engagement through wellness programs; pediatric residents aiming to learn more about whole-foods, plant-based nourishment)
What would you like your audience to gain after listening to Dr. Adame speak? If this is for an educational event, what are the learning objectives? Or if this is for school-based/corporate wellness consultation, what are your pain points and what outcomes are you searching for?  *
Number of attendees expected (for speaking engagements)
Would you like to schedule a complimentary consultation to discuss your organizations' needs?  *
Please use this space to note any additional details about the audience/event/school/organization that you would like Dr. Adame  or her team to know about
We are pleased that you are interested in booking Dr. Adame as a School-Based Nutrition Consultant, Corporate Wellness Ecosystem Consultant, Speaker at your upcoming event, or serving as your Emcee! Upon submission of this form,  a member of our team will contact you within 72 business hours. 
A copy of your responses will be emailed to the address you provided.
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