WHIS, 'Empowering Communities to Thrive' event form (W/01)
Thank You for your dedication to be part of our "Empowering Communities to Thrive" event. As you have elected to provide one or more of the following;- public speaking / lecture / workshop / activity / performance, we would like a little bit of information for our files. This information will both help us to drill down and organise events for the two days in question but will also be a starting point for our ongoing publicity of both the event and yourselves. Please complete as much information that you can and are happy to be shared in our publicity and future documentary work about the event.

Email address *
About You
Name *
Your answer
Your Bio *
Please provide a few sentences about yourself
Your answer
Your place of residence *
Profile Image
Please provide a link to a profile image you have on line This may be a profile image from a social media account or an image you hold in an online gallery or your website. Alternatively you can email an image to linda@worldhealthinnovationsummit.com. Please ensure you include your full name with the email so we can match your image to your form.
Your answer
About your organisation
Please provide us with information regarding your community project, group, business or organisation if relevant.
What you do & why *
Please provide a short summary about what your project, group or organisation does and why.
Your answer
Your Reach *
Please share with us the geographical areas that your project, business or organisation works. Please select more than one option if applicable
Required
More about your reach
Please use this space if you wish to tell us more about the geographical areas that you work in for example name of UK areas or specific global areas.
Your answer
Organisations digital presence
Please provide relevant web, blog and social media links for your project, business or organisation.
Website address
Your answer
Blog address
Your answer
Facebook page
Your answer
Twitter handle
Your answer
Youtube
Your answer
Instagram
Your answer
Other
Your answer
Your Schedule
Please provide as much information as you can to help us organise and plan fo the event. The next part of this form can be repeated upto three times to cater for those providing more than one talk or workshop. If you are providing more than 3 please use the other information box at the bottom of this form to include additional information regarding these.
Session 1
Session 1 : Summary *
Please provide a short summary of your first talk, activity or workshop here. If your talk has a name or title please also provide this here.
Your answer
Session 1 category *
Choose one category that predominates the overall theme of your story, workshop or talk.
Session 1 other
If yo selected "other" from the drop down menu above then please add information here to tell us what general theme you consider best describes your story, workshop or talks.
Your answer
Session 1 prefered days/times *
tick all that apply.
Required
Session 1 length *
Please provide us with an idea how how long you would prefer to have available when delivering your story, talk, activity or workshop. Please note these time slots are inclusive of any question and answer sessions. With this in mind you my wish to factor extra time onto your talk or workshop to accommodate this.
Resources required (1)
Please indicate if & what resources you may require from us on the day. There is space provided to add additional information about your desired requirements.
Other resources (1)
Please add any additional resources you may require here. Please indicate any other support you may require.
Your answer
Session 2
Session 2 summary
Please provide a short summary of your first talk, activity or workshop here. If your talk ahs a name or title please also provide this here.
Your answer
Session 2 category
Choose one category that predominates the overall theme of your story, workshop or talk.
Session 2 other
If yo selected "other" from the drop down menu above then please add information here to tell us what general theme you consider best describes your story, workshop or talks.
Your answer
Session 2 prefered days/times
tick all that apply.
Session 2 length
Please provide us with an idea how how long you would prefer to have available when delivering your story, talk, activity or workshop.
Resources required (2)
Please indicate if & what resources you may require from us on the day. There is space provided to add additional information about your desired requirements.
Other resources (2)
Please add any additional resources you may require here. Please indicate any other support you may require.
Your answer
Session 3
Session 3 summary
Please provide a short summary of your first talk, activity or workshop here. If your talk ahs a name or title please also provide this here.
Your answer
Session 3 category
Choose one category that predominates the overall theme of your story, workshop or talk.
Session 3 other
If yo selected "other" from the drop down menu above then please add information here to tell us what general theme you consider best describes your story, workshop or talks.
Your answer
Session 3 prefered days/times
tick all that apply.
Session 3 length
Please provide us with an idea how how long you would prefer to have available when delivering your story, talk, activity or workshop.
Resources required (3)
Please indicate if & what resources you may require from us on the day. There is space provided to add additional information about your desired requirements.
Other resources (3)
Please add any additional resources you may require here. Please indicate any other support you may require.
Your answer
Any other notes
Please use this space to provide us with any additional information, notes, questions or web addresses (URL's) that you think way may need to know or would help us build a more indepth picture about you and your work .
Extra Information
Your answer
Extra web links
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of The Journal Project. Report Abuse - Terms of Service