Mallory Cyr Speaker/Consulting Request Form

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Please fill out the following information, as well as anything that would be helpful for Mallory to know. Once the form is received, Mallory will be in touch to provide a quote for services and set up a time to further discuss the needs of your audience.

Email *

Name:

Organization: *

What is the date of your event? *

YYYY

Is the event virtual, or in person?

Virtual

In Person

Hybrid Model

Clear selection

What time would you like Mallory to present? *

Time

Is this time flexible? *

Yes

Other:

What type of presentation do you want Mallory to provide? (Please visit https://mallorycyr.weebly.com/services.html for further definitions of services) *

A keynote/plenary/guest lecture (60-90 minute solo presentation)

Join a panel with other participants

This is an ongoing project (please describe in comments)

Facilitate or moderate a workshop or small breakout session

Other (please explain below)

Required

If you said other for the last question, please describe the type of service you are requesting:

Please describe the size and makeup of the audience for this presentation (youth leaders, medical professionals, etc) *

Please provide some dates that work to set up an initial planning call with Mallory and anything else you think would be helpful to prepare.

Send me a copy of my responses.

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