First Name*

Last Name

Email*

Phone number*

Type of Presentation
No cost - 15-20 minute Informational Talk (Who we are and what we do)$100/hour - Workshop/training (Typically for staff training/education purposes)

Are you flexible on date and time? *
YesNo, we have a specific date/time in mind

Requested date for speaker (LEAVE BLANK IF YOU ARE FLEXIBLE)

Requested time for speaker (LEAVE BLANK IF YOU ARE FLEXIBLE ON TIME BUT NOT DATE

Website

EVENT INFORMATION

Name of organization and event organizer *

Address of the event *

City

State/Province
---AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip/Postal

Expected Attendance *

Length of presentation *

Is there the ability to use audio visuals? *

What do you hope to gain or learn from this presentation? *

Will there be an honorarium or offering taken up for Awaken?
YesNo

Can Awaken have an information / merchandise table?
YesNo

Any additional information you'd like the speaker or Awaken to know about this event?