Speaking Request Form

Contact Information

Name*

Email*

Phone*

Host Organization*

Size of Organization (If a church, typical ADULT attendance Sunday morning)*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Event Information

Event Name*

Location*

Event Dates*

Event Website*

Event Description*

(Purpose, # of speakers, etc.)

Attendee Description*

(e.g., pastors, church leaders, business leaders, adult men and women, teens)

Typical Attendance at a Hosted Seminar

Have you read our Host Guidelines (see above)?*

No
Yes, and they are fine with us.
Yes, and we would like to discuss them.

Have you specifically confirmed with your audio/visual team that you can provide the A/V setup specified in the Hosting Guidelines that allow our instructor to manage the PowerPoint & video presentation from his personal computer at podium?*

Yes
No
We may not be able to provide your preferred setup and would like to discuss alternatives

RW Seminar or Custom Speaking?*

RW Seminar
Custom Speaking

Please indicate what you generally pay for travel, lodging and materials expenses, as well as a speaker honorarium.

Instructor Preference*

We anticipate attendance of 250+ and would like Ken Sande to speak
Please recommend a Certified RW Instructor to serve us
Please recommend a Certified RW married couple to serve us

Gender Preference*

We would be happy with either a male or female instructor
We prefer a male instructor for this event
We prefer a female instructor for this event

Nearest Airport?*

Distance from Airport?*

Other Information

(e.g., if custom speaking request, how many plenary sessions and/or workshops would you like us to do?)

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