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Request A Speaker
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Contact Name
First
Last
Contact Phone Number
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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
Less than 25
25-50
50-75
75-100
100+
Audience Profile
Organization
Business
Non-Profit
Church/Faith Community
Students - Elementary
Students - Junior High
Students - High School
Students - College
Other
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
Prevention
Training
Crisis
Dinner/Banquet
Panel
Informational
Other
Select all that apply.
If other, please explain.
Media Equipment Provided
Microphone - Lapel
Microphone - Handheld
Microphone Stand
Projector
Screen
Podium/Stand
Computer
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
Honorarium
Airfare
Rental Car/Transportation
Hotel
Meals
None
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.
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