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Book Jess As A Speaker - Expression of Interest
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1.
Full Name
(Required.)
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2.
Email address
(Required.)
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3.
Phone Number
(Required.)
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4.
Organisation or Service Name
(Required.)
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5.
Your Role or Job Title
(Required.)
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6.
Event Title
(Required.)
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7.
Event Type
(Required.)
Conference or Symposium
Professional Development Workshop
Staff In-service / Planning Day
Webinar or Virtual Presentation
Panel or Discussion Forum
Other (please specify)
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8.
Proposed Event Date(s)
(Required.)
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9.
Proposed Location (If virtual, write “Online”)
(Required.)
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10.
Expected Audience Size
(Required.)
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11.
Audience Type
(Required.)
Early Childhood Educators
Teachers (Primary / Secondary)
Educational Leaders / Managers
Students (TAFE / University)
Parents / Community Members
Other (please specify)
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12.
Preferred Presentation Format
(Required.)
Keynote presentation
Workshop / interactive session
Panel discussion
Q&A / Fireside chat
Other (please specify)
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13.
Desired Duration
(Required.)
30 minutes
60 minutes
Half day
Full day
Other (please specify)
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14.
Topic or Focus Area
(Required.)
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15.
Why would you like to engage Jess for this event?
(Required.)
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16.
Budget (if known)
(Required.)
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17.
Any other information you’d like us to know?
(Required.)
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18.
I understand that submitting this form does not guarantee Jess’s availability, and that the Koori Curriculum team will review my request and contact me to discuss next steps.
(Required.)
Yes
No
