* indicates required field Organization & Contact/ * Contact Name * Company/Organization * Name of room/location where event will be held (e.g. school cafeteria, "Dwight" conference room, suite 1240, etc.) * Street Address * City/Town * State Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming * ZIP * County * Contact Email Address * Confirm Email Address * Phone Number * How did you find out about our Speakers Bureau services? (Please select all that apply) EmailEventFamily or FriendInternet SearchNewspaper ArticlePhone callSocial MediaOther If you selected 'Other' above, please specify: Event Details * Date of Event * Time of Event If the event details are being considered upon the Speaker's availability, you may leave this option blank to indicate that the date/time are "flexible. Please Select... 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM * How much time will the speaker have to present? Select Duration... Less than 30 mins 5 - 10 mins 15 - 20 mins 20 - 30 mins 30 - 45 mins 1 hour 1 - 2 hours Other If you selected 'Other' above, please specify: Speaking Engagement: Topic and Format * Subject/Topic (e.g. "Eating right, doesn't mean you eat what's left") = Nutrition Education * What is the specific purpose of the meeting? (e.g. awards banquet, annual meeting, etc.) * What is the format of the event? (e.g. Town Hall, Roundtable, etc.) * What is the appropriate dress code? (e.g. informal, business attire, etc.) Audience Details * How many people are expected to attend? Select Number... 10 - 15 15 - 20 20 - 30 30 - 40 40 - 50 50 - 75 75 - 100 100 - 200 200plus Other If you selected 'Other' above, please specify: Does your audience have a language preference? NOTE: most presentations are conducted in English. Some foreign language requests can be met - based on request and speaker availability. EnglishSpanishOther If you selected 'Other' above, please specify: * Type of industry/companies represented by your group? Please select in consideration of your audience base Select Number... Agriculture Business or Corporate or Financial Construction Customer Service Education Energy Entertainment Food Services or Restaurant Government Healthcare Hospitality or Tourism Media Technology Other If you selected 'Other' above, please specify: * Are there particular industry challenges, breakthroughs, and/or problems facing your group? (e.g. construction industry = back pain and injury) Other Speaker(s)/Otro(s) conferencista(s) * Are there other speakers at this event? YesNo Please specify the names and topics of the other speaker(s) who will be presenting Speaker Name/Topic Speaker Name/Topic Speaker Name/Topic Medios de prensa * Will media be present? YesNo * Please select all media outlets RadioNewspaperNews StationsMagazinesBlogs Please list the names of the media companies Audiovisual Support * Will there be any audiovisual support? YesNo * Audiovisual support details Please check all that apply. MicrophoneFlipchartDry erase boardFree-standing PodiumTable PodiumExtension CordsProjectorLaptopOther If you selected 'Other' above, please specify: Additional Information * Would you like to receive news and updates about Parkland by email? YesNo Is there anything else we need to know about your group/event? If YES, please explain. Please enter the letters you see below