Speaker Request
We have a number of speakers that will motivate and inspire any group you are working with.
* Required
First Name
*
Last Name
*
Email
*
Phone
*
Address 1
*
Zipcode
City
*
State
*
Preferred Contact Method
*
Email
Phone
Mail
Speaker/Facilitator
*
Andre Koen
Jimmie Heages
Organization
*
Select your orgizational type
K12 School
College / University
Government
Not-for-profit
Faith based
Community organization
Youth Rally/School
Trade Association
Expo/Convention
Conference
Church Event
Other:
Services
*
Select services you would like information about
Ethic/Bias Training
Cultural Competence
Leadership Development
General Diversity Education
Personal/Professional Leadership
Workplace Diversity
Team Building
Change Management
Cultural Specific Training
Staff Development
Strategic Planning
Other:
Certifications
Will this course be used for Continuing Education Credits?
CLE
CEU
Ethic/Bias Credits
Diversity CEUs
Service Delivery
*
Select the service delivery method
Online Coaching
Online Courses
Live Presentations/Webcasts
Half-Day Workshops (2-3 hours)
Full Day Workshops (3+ h
Telephone Coach
DVD/CD-rom Presentaions
Keynote/Presenter (60 - 90 minutes)
Other:
Purpose of Appearance: (choose)
*
Keynote with Book signing (90 minutes)
Keynote Address (45-60 minutes)
Question and Answer (Q&A) Session (30-45 minutes)
Double_Block Booking (Negotiable) (One or session in one or two days)
Training Sessions
Coaching
Other:
Audience Demographics
*
Select your type of group
Adults
Young Adults
Youth
Children
Group size 1-20
Group size 20 -50
Group Size 50-70
Group size 70+
Professionals
Novices
Community members
Other:
Purpose of Appearance: Program name
*
Date:
*
Start time:
*
End time:
*
Address of Location for Training Event:
*
Venue Type: (Hotel/Convention Center/Church etc.)
Promotional Interviews: (Print, TV and Radio)
Budget Range:
*
Please Specify Buget Range
$1,000-$1,499
$1,500 - $4,999
$5,000+
Other:
Room Configuration
*
Please give us information about the room
Classroom style
U Shape Formation
Auditorium Stage
Auditorium -No stage
Board Room
Conference Hall
Conference Hall-no head table
Other:
Audio/Visual Equipment Availible
*
Audio/Visual Equipment Availible
LCD Projector
Wireless Microphone
Wired Microphone
Lav. Microphone
DVD/VCR Player
Laptop
Overhead projector
Laptop Speakers
TV
LCD TV
Projector screen
No A/V at all availible,event does not support this
No A/V at all availible, please bring your own
I do not know what A/V is availible
Questions or Comments
How did you hear about us?
*
Email Campaign
Postal Mailing
Referred by Andre'
Referred by Lori
Web Surfing
Referred by County
Other: