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Speaker Request Form

Thank you for your submission.

Thank you for your request. We will be in touch with you shortly.

Event Primary Contact Name(required)

Title

Organization

Organization Type

For profit Non-profit Political Organization

Primary Contact Email(required)

Primary Contact Phone Number(required)

Phone Type(required)

Organization Website

Is the primary contact the same as the “day of the event” contact?(required)

Yes No

How did you hear about us?

Topic(s) Desired (choose one or more options)

WSCC Model Community Schools Comprehensive Sexuality Education Ethnic Studies Social Emotional Learning Other

Event Name/Title(required)

Event Website or Social Media Link(required)

Host Organization

Event Start Date (MM/DD/YYYY)(required)

Event End Date (MM/DD/YYYY)(required)

Number of Guests Expected(required)

Date of Speaking Engagement (MM/DD/YYYY)(required)

Time of Speaking Engagement(required)

Presentation Format(required)

Alternative or Additional Speaking Dates and Times:

What is your payment offer for the event speaker?(required)

Event host agrees to pay for speaker hotel accommodations, flight costs, transfers and meals?(required)

Yes No

At what hotel will the speaker be staying?(required)

Event venue name and address(required)

Provide a brief description and goal of the event:(required)

Describe who will make up your audience:(required)

Additional Detailed Information: Number of events or meetings to attend, requested radio appearances or podcasts, and length of training(s) or speech(es)(required)

Additional Comments:

By submitting your information, you’re giving us permission to email you. You may unsubscribe at any time. By submitting this form, it is understood that all travel arrangements and communication must be coordinated with A Time To Stand.

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