Shake Up Learning: Speaking Request Form
Professional Development/Speaking Request

Thank you for your interest in Shake Up Learning services. Please complete the form below. I will contact you about this request as soon as possible.

The cost of event varies and will depend on the options chosen below. Please do not request multiple events on one form.
District/Organization *
Name *
Title *
Email Address *
Phone Number *
How did you hear about Kasey Bell? *
Type of Service * *
Please choose the type of service that will help meet your needs. (check all that apply)
Required
Name of Event *
Event Hashtag
Topic(s) Requested/Details of What You Need for Your Event *
Please be specific on what topics you would like covered. Please let me know if this is a multi-day event.
Date of Event (first choice) *
MM
/
DD
/
YYYY
Date of Event (second choice)
MM
/
DD
/
YYYY
Where? Location of the event. *
Please include the physical address if available.
Nearest Airport *
Capacity *
Please indicate the capacity of the location. Hands-on workshops are usually limited to between 12 and 30 participants, with 20-25 being ideal. Keynotes and breakout sessions may of course include a higher number of participants.
Equipment Available *
Please indicate the operating system, software, peripherals, and Internet connection(s) available at the location. Include other technical details as necessary.
Technical Support *
Please indicate who will be responsible for technical support at the location. Provide contact information if possible.
Event Coordinator/Logistical Support *
Please indicate who will be responsible for logistical support (such as registration) at the location. Provide contact information if possible.
Audience *
Please indicate if the topic should be focused for a particular audience, such as administrators or teachers of a specific grade or subject.
Audience Level *
Expected number of participants *
Details of Your Needs/Goals *
Please provide a list of goals for this workshop, including the level of participants. For instance, first year implementing G Suite and/or chromebooks, etc.
Would you like to purchase the Shake Up Learning book for your participants at a bulk rate? *
Shake Up Learning T-Shirts
Would you like to purchase Shake Up Learning t-shirts for your team or participants? *
Will Your Event Have an Exhibit Hall for Vendors? *
Please provide a list of goals for this workshop, including the level of participants. For instance, first year implementing G Suite and/or chromebooks, etc.
Billing Address *
Proposal Approval *
Please indicate the name, title, address, email, and phone number of the person for whom the proposal should be prepared if you will not be signing the proposal.
Submit Your Request
The cost of events varies and will depend on the options chosen below. I will provide you with a customized proposal and quote based on the options you selected.

NOTE: You must click submit below for your answers to be recorded.

You may contact Kasey directly with further questions here: Kasey@ShakeUpLearning.com.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy