Speaker/Guest Appearance Request Form
Please take a few moments to complete the questions below to request Kimesha to speaker at your event or appear on your show. Kimesha or her assistant will follow-up with you shortly about your request!
* Required
Email
*
Your email
Name
*
Your answer
Email
*
Your answer
Phone
Your answer
Organization
*
Your answer
How did you hear about Kimesha?
*
Business Colleague or Friend
Search Engine
Social Media
Direct Mail
Past Event
Other:
Required
Event Date
*
MM
/
DD
/
YYYY
Event Time
*
Time
:
AM
PM
Event Location
*
Your answer
Number of Attendees
*
Your answer
Speaking Topic
*
Your answer
Describe Audience
*
Your answer
What are some challenges they maybe facing? What are some key take-aways you want your audience to leave with.
*
Your answer
Length of Presentation
*
15-30 minutes
30-60 minutes
1-2 hours
2-4 hours
upto 8 hours
Type of Event
*
Teen Dating Violence Awareness
Domestic Violence Awareness
Conference
Retreat
Teen Expo
Book Club
Gala
Birthday Party
Meet & Greet
Media Appearance
Other:
Speaking fee budget
*
Your answer
Discount or Code
Your answer
Press Kit
*
Please send me a press kit
I will view press kit and video online
Required
Next
Never submit passwords through Google Forms.
This form was created inside of Kimesha Coleman Coaching.
Report Abuse
Forms
