Thank you for taking the time to fill out this questionnaire. A few moments spent answering these simple questions will help make the presentation go as smoothly as possible. If your would prefer to fax the form to us, click here for a printable version (PDF, 46KB).
Items marked with * are required. |
School: |
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School address: |
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City: |
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State/Province: |
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School phone (with area code): |
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School fax (with area code): |
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* Contact person: |
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Contact phone (with area code): |
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After-hours phone (with area code): |
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Presentation date: |
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Type of event (i.e. conference, workshop, etc.): |
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Theme of event: |
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Type of presentation: |
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Speaker you are interested in: |
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If you chose "other" above, please name: |
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Anticipated audience size: |
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Goals for this presentation: |
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Describe age, experience, and expectations of your audience: |
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Presentation venue: |
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Speaker will be staying at (i.e. name of hotel): |
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Closest airport: |
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Ground transportation will be handled by: |
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If speaker is to rent a car or use a taxi, please provide detailed driving directions to event and lodging locations: |
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For the purposes of flight scheduling, the speaker will begin his/her portion of the program at: |
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...and will be able to leave by: |
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Distance to airport (in minutes): |
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Form completed by: |
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Title: |
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| If you have arranged for other schools to use this speaker during his/her visit, please ask them to fill out this form as soon as possible. They will also need to read our Tips for a Great Presentation. If you prefer, you may e-mail us with their names and contact information and we will contact them directly. If you have any questions or concerns, please call 1-800-658-6082 between 9am and 6pm MST or e-mail bookings@differencemakers.com. |
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Please enter the security code you see above in this box:
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