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INQUIRY FORM
— LEAP® & Anosognosia Training
This form is for organizations, teams and communities only.
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Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
ORGANIZATION
*
Your answer
CONTACT — Full Name
*
Your answer
Title
*
Your answer
Phone
Your answer
How did you hear about LEAP?
*
Your answer
Has a LEAP Faculty / Dr. Amador previously presented to your organization?
*
NO
YES (please list timeframe below)
Other:
Required
FORMAT
—
What type of session are you requesting?
*
Keynote / Overview (1 - 1.5 hr)
Virtual Training (2 - 3 hr)
In-Person Training
Other:
Required
TIMEFRAME — When do you want this session conducted?
*
Your answer
GOAL
—
What do you expect to accomplish with this session?
*
Your answer
EVENT
—
Is this session part of a larger event?
*
NO
YES (enter event info below)
Other:
Required
PRESENTER - Do you have presenter requirements?
*
LEAP Faculty
Dr. Amador Only
Other:
Required
FEE
—
Do you plan to charge for this session?
*
NO
YES
Other:
BUDGET
—
What budget /range is allocated for this session?
*
Your answer
AUDIENCE — Who will be attending?
(list roles, location/s, other relevant info)
*
Your answer
How many attendees?
*
Your answer
ACCESS - How will participants be invited to attend this session?
*
Private - Selected Attendees (by invitation only)
Private - Internal (within organization only)
Semi-Private - Internal Organization & Selected Community Partners
Public - Open to Community
Other:
Required
DEADLINE
—
Are you working within a deadline to confirm this session?
*
Your answer
ADDITIONAL COMMENTS
Your answer
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