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Speaker Request Information Form

First Contact Person's Name

First Name*

Last Name*

Phone*
First Contact Person's Date of Birth*
I certify that I am 18 years of age or older
First Contact Person's Signature*
Second Contact Person's Name

First Name*

Last Name*
Second Contact Person's Date of Birth*
Third Contact Person's Name

First Name*

Last Name*
Third Contact Person's Date of Birth*
Fourth Contact Person's Name

First Name*

Last Name*
Fourth Contact Person's Date of Birth*
Fifth Contact Person's Name

First Name*

Last Name*
Fifth Contact Person's Date of Birth*
Sixth Contact Person's Name

First Name*

Last Name*
Sixth Contact Person's Date of Birth*
Seventh Contact Person's Name

First Name*

Last Name*
Seventh Contact Person's Date of Birth*
Eighth Contact Person's Name

First Name*

Last Name*
Eighth Contact Person's Date of Birth*
Ninth Contact Person's Name

First Name*

Last Name*
Ninth Contact Person's Date of Birth*
Tenth Contact Person's Name

First Name*

Last Name*
Tenth Contact Person's Date of Birth*
Parent or Guardian's Email Address

Email
Check to receive information by e-mail.
A signed copy of this waiver will be sent to the email address you provide.

Date of request *

Requesting group/event name *

Best time of day to reach contact person by phone

Topic desired *

Potential dates *

Desired location and time of day *

Expected number and age group of audience *

Other description of audience

Budget for event *

Questions or other information
You will be contacted by phone within one business day once this form is received and reviewed. Thank you for your interest!
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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