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Speaker Request form
Please complete the following form to provide information about speaking services
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* Indicates required question
Contact Person Name, Phone, Email, Role in Organization
Your answer
Organization Name
*
Your answer
Date of Event
*
MM
/
DD
/
YYYY
Time of event
*
Time
:
AM
PM
Duration of event
Time
:
AM
PM
Expected number of attendees
*
Your answer
What service(s) are you looking for?
*
Workshop
Keynote
Private Retreat
Consultation
Staff Retreat
Other:
Required
What topics are you interested in learning? (click all that apply)
Self Care
Burnout prevention/management
Mindfulness
Nature wellness
Grief
Self Love
Identity/Esteem
Description of event
*
Your answer
Please describe in detail what you are interested in getting support with. What is your goal? What do you want your audience to take away? Include activities, topics, ideas, etc.
*
Your answer
What is your budget?
*
Your answer
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