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Speaker Request
Speaker Request Form
Full Name
Title
Email
Phone
Name of Organization
Website of Organization
Name of Event
Date of Event
Time of Event
Event Location
Virtual
In Person
If in Person Please Provide Full Address
Erica is located in the DMV, will travel accommodations be needed?
Yes
No
N/A
Expected Number of Attendees/Participants
What is your speaker budget?
Type of Presentation Requested:
Guided Meditation
Keynote Address
Event or Panel Moderator
Panel Discussion
Workshop/ Training
Other special requests (check all that apply):
Meet and Greet
Question and Answer
Speaker Attendance at Breakfast, Lunch, Dinner or Reception
Photo / Video permission
Media Interviews
Other
What do you want attendees to get out of your event?
How long is Erica St. Bernad, LCMFT being asked to speak and engage in the event?
Can products be sold at this event?
Yes
No
Any other information or details you would like to note?
Submit
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