Request A Speaker

Organization/Company Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Name

First

Last

Contact Phone Number

Contact Email Address

EVENT INFORMATION

Date & Time

Date

Time

Setup Time

Description of Event

Please provide a brief description of the event, including event type (ie: men's breakfast, women's luncheon, school assembly, etc.), event focus/topic, and any other relevant details.

Location

Please include address any other relevant details such as building name, room number, etc.

Number of Attendees

Audience Profile

Select all that apply.

If other, please explain.

PRESENTATION INFORMATION

Duration

Less than 30 minutes
30-45 minutes
45-60 minutes
1 hour+

Presentation Type

Select all that apply.

If other, please explain.

Media Equipment Provided

Select all media equipment that will be provided by the event location for use.

Media Elements Needed

PowerPoint
Thumb Drive
SD Card Reader

Would you like us to set up a merchandise table?

Yes
No

SPEAKER INFORMATION

Available Speakers

Lisa Bownds - CEO/Founder
Samye Flock - Prevention & Education Director
Leslie Rodriguez - Director of Operations
Robert Fowler - Community Partnership Director

Please select 2-3 options to ensure maximum availability.

Speaker Topic

If you have a specific topic or focus you would like the presentation to follow, please list it here.

Travel & Expenses

Please select all that your company/organization will be providing.

Travel Expenses Agreement

By clicking here, you indicate your agreement to reimburse Reflection Ministries for all travel expenses outside of Midland/Odessa, including mileage, airfare, hotel, and car rental.