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First Name*

Last Name*

Email*

Requested Event Date*

Year/Month/Day

Care Net Affiliate?*

Event Contact Name*

Event Contact Email*

Event Contact Phone (Mobile)*

Event Onsite Contact Name*

Event Onsite Contact Phone (Mobile)*

Type of Event*

Event Location*

Event Street Address*

Event City/St/Zip*

Nearest Airport to Event*

Transport Time between Airport and Hotel

Transport Time between Hotel and Venue

Lodging for Speaker (If Known)

Start/End Time for Event*

Length of Presentation (minimum 40min)*

Topic of Presentation*

Number of Attendees*

Audience Profile*

Can you accommodate a book signing following the event program?*

Yes

Can you provide a laptop and small table near podium for Roland to advance presentation slides?*

Yes

Can you provide a privacy monitor on platform or stage for Mr. Warren to see his slides during the presentation?*

Will the presentation be recorded?

Yes

Can you meet the Audio/Visual Requirements?*

Audio and video capabilities, wireless lavaliere microphone, projection screen and 32 inch privacy monitor on platform which will also be a feed from the big screen, thus mirroring the laptop view. A small cocktail table for laptop (center provided laptop) with remote advancer near podium to advance PowerPoint slides.

Yes

Do you Agree To Honorarium Terms? (For Pregnancy Centers Only: $5,200 Non-Affiliate: $5,700) *hosts are responsible for lodging.

Yes

Digital Signature*

Please type your full legal name as a digital signature to complete your speaker request