CONTACT / BOOKING FORM
I would love to provide you with a personalize proposal on how best you can book the Digital Empowerment Project and the associated costs. Please take a few seconds to complete this interest form and after submission I will email you with information on the speaker fee and other related details. If you would me to reach out to you via the phone, just check the appropriate box below. Otherwise, I will use your email and send you an absolutely NO OBLIGATION quote within 24 hours of your submission. I am excited at the opportunity to provide you with more information. Thank you again for your interest. If you simply want me to pick up the phone and call you (smile), just fill in your name, email and phone number and I will do just that!
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TYPE OF CONTACT:
GENERAL INQUIRY ONLY
REQUEST A NO-OBLIGATION PROPOSAL
SCHEDULE A PRESENTATION!
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NAME:
*
Your answer
PHONE NUMBER:
Your answer
EMAIL:
*
Your answer
NAME OF YOUR SCHOOL OR ORGANIZATION:
Your answer
TYPE OF ORGANIZATION:
(CHOOSE ALL THAT APPLY)
SCHOOL
PLACE OF WORSHIP
CIVIC OR PARENT GROUP
BUSINESS
ASSOCIATION OR ORGANIZATIONAL CONFERENCE
OTHER
IF YOU SELECTED "OTHER" ABOVE PLEASE EXPLAIN:
Your answer
LOCATION OF WHERE YOU WOULD HOST A DIGITAL EMPOWERMENT EVENT:
(INCLUDE ADDRESS SO THAT THE TRAVEL FEE CAN ACCURATELY BE DETERMINED)
Your answer
WHAT TYPE OF DIGITAL EMPOWERMENT EVENT ARE YOU CONSIDERING?:
(SELECT ALL THAT APPLY)
A FULL DAY OF EMPOWERMENT (YIPEE!)
DIGITAL EMPOWERMENT FOR PARENTS
DIGITAL EMPOWERMENT FOR EDUCATORS OR COUNSELORS
DIGITAL EMPOWERMENT FOR TEENS/STUDENTS
DIGITAL EMPOWERMENT SPLIT SESSION (ONE HOUR TEENS/PARENTS THEN ONE HOUR PARENT ONLY)
CONFERENCE BREAK-OUT SESSION (PROVIDE DETAILS IN COMMENT SECTION)
CONFERENCE KEYNOTE ADDRESS (PROVIDE DETAILS IN COMMENT SECTION)
PREFERRED EVENT TYPE IS NOT LISTED ABOVE
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ADDITIONAL DESCRIPTION FOR EVENT TYPE:
Your answer
IF YOU ARE SCHOOL, PLEASE TELL ME ABOUT YOUR SCHOOL INCLUDING YOUR STUDENT POPULATION:
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DO YOU HAVE A PREFERRED DATE FOR YOUR EVENT?:
MM
/
DD
/
YYYY
HOW WOULD YOU LIKE TO BE CONTACTED?:
CONTACT ME BY PHONE
CONTACT ME BY EMAIL
HOW DID YOU HEAR ABOUT THE DIGITAL EMPOWERMENT PROJECT?:
Your answer
ADDITIONAL COMMENT OR QUESTION:
Your answer
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