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Speaker and Trainer Request Form
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Organization Name
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Full Name of Point of Contact (POC)
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Email Address
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Phone Number
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Address for Event or Training
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Speaker Duties
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Panelist
Keynote Speaker for Event
Speaker
Breakout Session/Workshop
Other
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Level of Training Requested
Beginner (101: Basic definition and local data...prerequisite for all other levels)
Intermediate (201: Works with vulnerable populations and already has basic knowledge)
Advanced (Professionals: First responders, Service providers, etc....)
Not applicable to training I am requesting
Topics
Sex Trafficking
Labor Trafficking
Community-Specific Resources
Traffick911: TRAPS of a Trafficker (ages 12+) (Single 2-hour session)
iEmpathize: Empower Youth Program (Ages 10+) (Five 1-hour sessions)
JusticeActs: TraffickProof Program (ages 10-18) (Single 1-hour session)
Christian, Scripture-Based teaching
Armor of God: equipping students and adults to stand against the Original Exploiter
Outdoor Education to promote Self-Reliance and reduce vulnerability to Exploitation
Personal Value and Identity
Please specify any any special questions or requests you have for training.
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Dates Requested (top 3 choices, in order of preference)
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Arrival time for Set Up of presentation
Time
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AM
PM
Presentation Start Time
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Time
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AM
PM
Presentation Length
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Number of Attendees
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Focus/Objective of Event
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Will there be other speakers?
Yes
NO
Clear selection
Venue Audio Visual Capabilities
Projector - HDMI
Projector - VGA
Screen
Sound System - microphone, speakers
Computer
DVD
None of the above
Other:
Will there be an informational table for ARK2Freedom?
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Yes
No
Maybe
We ask that your group or business would cover the cost of our team's time. Please review the following options associated with your request.
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Keynote Speaker Fee Ranges from $150-500 depending on location, time, allotted to speak, and subject matter. More travel fees may apply.
Human Trafficking 201 Course or other advanced courses - Donation of $50 an hour to cover time, gas, and materials.
Guest Speaker or Panel Guest - Fees Range from $25-$200 an hour depending on subject matter, speaker, and time commitment.
All other requests will be reviewed. We ask that your Small Group, Church Group, or Business Group would commit to requesting a donation for the Speaker's time during the event.
I can not commit to payment/donation at this time.
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Anything else we should know?
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