Speaker or Media Request Form

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Speaker or Media Request Form

Please answer the following questions to book BIPOC Dance Health for content or speaking engagement.

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* Indicates required question

Email *

Your email

Name of Individual making the request *

Your answer

Name of Organization *

Your answer

Organization website *

Your answer

What type of service are you requesting? *

Interview

Panel

Speaking Engagement

Other:

Audience Size *

Your answer

Location of Presentation or Media Type *

Your answer

Estimated Budget for Speaker or Content *

Your answer

Event Date *

MM

/

DD

/

YYYY

Event Topic *

Your answer

Event Goals *

Your answer

Any other details *

Your answer

Send me a copy of my responses.

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