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PR/Media Request Form
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Today's Date
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MM
/
DD
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YYYY
Your Name
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Your answer
Phone Number
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Your answer
Email
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Your answer
Who are you requesting to be interviewed?
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Your answer
Type of Media
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Choose
TV
Radio
Newspaper
Magazine
Other
Name of Organization (Show, Publication, Newspaper)
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Your answer
What is the estimated reach of your outlet?
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Your answer
Will you be sharing the story/interview across your social media? If yes, what platforms and estimated social media reach?
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Your answer
Length of Interview/Segment
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Your answer
Proposed Date/Time (PST) Please add additional dates/times as options if possible.
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Your answer
Requested Location (please specify Zoom, Skype, in-person, etc.)
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Your answer
Requested Arrival Time
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Your answer
Select all topics to be discussed:
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Faith
Do Something Church (Outreach)
The Third Option (Racial Reconciliation)
The Third Option (Similarity Training)
Leadership
Current Event
Other:
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Point of Contact
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Your answer
Time of Broadcast/Issue
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Your answer
Deadline for Response
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Your answer
Any other details?
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Your answer
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