Event OrganizerRequesting Organization:*Organization Mission:*Event Contact Name:* First Last Contact Title:E-mail:* Phone Number:*Event DetailsEvent Name:*Event Website: Describe the vision and theme for this event:*Type of Request:*Keynote SpeakerPanelistBreakout Session Speaker1 or 2 Day Workshop/TrainingEvent Type:*Will there be other speakers at this event:*YesNoDate of Event:*Time of Event:*Location of Event (include address)*Potential Audience Size:*0 to 25 attendees26 to 50 attendees50 to 100 attendees100 to 200 attendeesDescribe the audience demographic:*Describe the subject or main focus of requested talk:*Time allotted for talk:*Attendee ExperienceDescribe what you want your attendees to experience:*Describe the layout of the room:How do you define success of a conference?*How would you define the most valuable takeaway for your attendees?*Cost of attendance:*Will media be present?*YesNoIf yes, what media outlets will be present?Attire:*Speaker budget:*Will there be audio/visual capabilities?*YesNoWould you like to learn about our day trainings, workshops and other value-add services?*YesNoAdditional information you would like to share:*All information obtained by Stephanie B. McAuliffe and Reclaiming Your Self, LLC in relation to the Client shall remain confidential and, except as may be required by law, we shall not, without the Client’s prior written consent, disclose or divulge to any third party any information of any nature whatsoever in relation to the Client. Information collected from the Client is used solely for the completion and coordination of Services, and client information will never be sold, shared, misused or referred intentionally to other sources.
