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Speaking Request Form
Thank you for your interest in having Gena speak at your next event!
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* Indicates required question
Email
*
Your email
Your Full Name
*
Your answer
Organization Name
*
Your answer
Organization Contact Number
*
Your answer
Organization Event Name
*
Your answer
Organization Event Date
*
MM
/
DD
/
YYYY
Organization event time
*
Time
:
AM
PM
Type of Event
*
In-Person
Virtual
Event Location
(In-Person Only, Venue Name and Full Address)
*
Your answer
Expected Talk/What would you like Gena to discuss at this event
*
Your answer
Length of requested talk
*
Your answer
Expected number of audience members
*
Your answer
Demographic of audience members
*
Your answer
When considering the organization and audience members, what would make this talk a success?
*
Your answer
What is your budget for this event
*
Less than $500
More than $500
Will your organization cover travel & lodging expenses?
*
Yes
No
Will the event be professionally recorded?
*
Yes
No
When do you need an answer from Gena
*
Your answer
Any other important info you'd like to share
*
Your answer
A copy of your responses will be emailed to the address you provided.
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