Speaker Request Form
Please fill out this questionnaire to request a speaker from Courage Worldwide at your event.
Contact Person
Contact Person First Name *
Contact Person Last Name *
Email *
Phone *
Have you already been in contact with someone from Courage Worldwide regarding this event? *
If yes above, who?
Organization Information
If this event is been hosted by an organization or is affiliated with an organization, please fill out Organization Information below. If not, you may skip to Event Details
Organization Name *
If not applicable, please put "none"
Website (if applicable)
Tell us about your organization.
Event Details
Date and Start Time of Event *
MM
/
DD
/
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Time
:
Venue Name *
Venue Address *
Type of Event *
Tell us about the event. *
Length of presentation
Target audience *
Expected number of attendees *
Are you able to provide a speaker honorarium? *
Are you able to reimburse for travel expenses? *
Can merchandise be sold at this event to support Courage House? *
(For groups of 40 or more)
Would a financial ask be appropriate for this venue? *
Submit
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