Speaking Engagement Intake Form

Full Name *

Organization/Company Name *

Job Title *

Email Address *

Phone Number *

Event Name *

Event Date *

Event Time (in EST) *

Event Location: *

In-Person (Please provide exact address)
Virtual (Please provide platform link and access details)

Expected Audience Size *

Audience Type *

Parents

Healthcare Providers

Community Health Workers

Business Owners/Entrepreneurs

Others

Audience Goals/Expectations for the Presentation *

Requested Topic(s): *

Maternal Health and Postpartum Care

Delegation as a Superpower

Empowering Caregivers Through Self-Care

Custom Topic:

Length of Presentation *

15-30 minutes

30-60 minutes

Keynote (60+ minutes)

Panel Discussion

Will There Be a Q&A Session? *

Yes

No

Will You Provide AV Equipment (for in-person events)?

Yes

No

If No, please specify if speaker needs to bring any equipment

Will the Event Be Recorded? *

Yes

No

Budget for Speaker Fee (if applicable) *

Other Compensation Offered (e.g., travel, accommodations)

Any Additional Details or Requests for the Presentation *

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