Speaker Request Form

Please fill out this questionnaire to request a speaker from Courage Worldwide at your event.

Contact Person

Contact Person First Name

This is a required question

Contact Person Last Name

This is a required question

Phone

This is a required question

Have you already been in contact with someone from Courage Worldwide regarding this event?

This is a required question

If yes above, who?

This is a required question

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"

This is a required question

Website (if applicable)

This is a required question

Tell us about your organization.

This is a required question

Event Details

Date and Start Time of Event

Venue Name

This is a required question

Venue Address

This is a required question

Tell us about the event.

This is a required question

Length of presentation

This is a required question

Target audience

This is a required question

Expected number of attendees

This is a required question

Are you able to provide a speaker honorarium?

Yes
No
Unsure

This is a required question

Are you able to reimburse for travel expenses?

Yes
No
Unsure

This is a required question

Can merchandise be sold at this event to support Courage House?

(For groups of 40 or more)

Yes
No
Unsure

This is a required question

Would a financial ask be appropriate for this venue?

Yes
No
Unsure

This is a required question