Speaker Request * 1. Requestor contact information Name Email Address Phone Number * 2. Event name * 3. Event host contact information Name Address Address 2 City/Town State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number * 4. Event or host organization website * 5. Event Start Date Date * 6. Event End Date Date * 7. Speaking start time Time - AM PM * 8. Event type Lecture or Classroom Worship Service Conference Seminar "Ted Talk" Style/short speech On-Stage Interview Fundraiser Other (please specify) * 9. Venue Venue Name Venue Address City/Town State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * 10. Event Description * 11. Call to Action Child Sponsorship Refugee Responder Pledge (Water, Micro, Women's Empowerment) Advocacy Every Last One Fundraising Campaign N/A Other (please specify) * 12. Other Event Goals * 13. Preferred Speaker(s) * 14. Speaking format Keynote Sermon Panel Interview Workshop Other (please specify) * 15. Presentation Topic * 16. Presentation length of time (in minutes) * 17. Audience demographic Adult Youth Women Men Multicultural Faith-based Secular Professional Community Leaders Pastors College Students Ministry Leaders Philanthropists Other (please specify) * 18. Attendance (estimated total number of attendees) * 19. Event Logistics Answer Honorarium or Travel Reimbursement Available? Yes No Maybe Honorarium or Travel Reimbursement Available? Answer menu May we offer child sponsorship or the refugee responder pledge at your event? Yes No Maybe May we offer child sponsorship or the refugee responder pledge at your event? Answer menu Will this event be video recorded? Yes No Maybe Will this event be video recorded? Answer menu * 20. How did you hear about the World Vision Speakers Bureau World Vision Employee Word of mouth Church/Pastor Conference MOPS RCMA Aspire Magazine Other (please specify) * 21. Other comments or special requests * 22. Evaluations are essential to our success. Please provide the email address of the person who will fill out the speaker evaluation. 100% of survey complete. Done
