Speaker Request Form - Vital Ability, LLC

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Speaker Request Form

Thank you for your interest in inviting Vital Ability LLC to speak at your event.

Please complete the information below so we can better understand your event, audience, and presentation needs. We will review your request and contact you as soon as reasonably possible.

How did you hear about us?

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Organization Information

Organization Name: {"type":"text","name":"__generic2","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Primary Contact Name: {"type":"text","name":"__generic3","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

Title/Position: {"type":"text","name":"__generic4","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Email Address: {"type":"text","name":"__generic5","width":40,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

Phone Number: {"type":"text","name":"__generic6","width":50,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"(000) 000 - 0000"}

Organization Website (if applicable):

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What is the best way to contact you for follow-up from this form? Phone call Text Email Video Chat{"type":"checkbox","name":"__generic8","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Phone call\nText\nEmail\nVideo Chat"}

Event Information

Event Name {"type":"textarea","name":"__generic9","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Event Type (check all that apply)

Conference Convention Professional Development Staff Training Educational Workshop Webinar Community Event Support Group Leadership Meeting Lunch & Learn Podcast Interview Panel Discussion Other{"type":"checkbox","name":"__generic10","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Conference\nConvention\nProfessional Development\nStaff Training\nEducational Workshop\nWebinar\nCommunity Event\nSupport Group\nLeadership Meeting\nLunch & Learn\nPodcast Interview\nPanel Discussion\nOther"}

{"type":"textarea","name":"__generic11","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"If other, please explain here"}

Presentation Date {"type":"text","name":"__generic12","width":35,"value":"","size":"Normal","validation":"DV","validationMessage":"Please fill in this item.","placeholder":"00/00/0000"}

Alternate Date (if flexible) {"type":"text","name":"__generic13","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"00/00/0000"}

Presentation Time {"type":"text","name":"__generic14","width":50,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Time Zone {"type":"text","name":"__generic15","width":25,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Presentation Length Requested

Choose length30 Minutes45 Minutes60 Minutes90 MinutesHalf-DayFull-Day{"type":"select","name":"__generic16","width":100,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Choose length\n30 Minutes\n45 Minutes\n60 Minutes\n90 Minutes\nHalf-Day\nFull-Day"}

Audience Information

Estimated Number of Attendees

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Audience Type

Healthcare Professionals Educators Coaches Caregivers Brain Injury Survivors Students Business Professionals Community Members Nonprofit Organizations Government Agency Mixed Audience Other{"type":"checkbox","name":"__generic18","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Healthcare Professionals\nEducators\nCoaches\nCaregivers\nBrain Injury Survivors\nStudents\nBusiness Professionals\nCommunity Members\nNonprofit Organizations\nGovernment Agency\nMixed Audience\nOther"}

{"type":"textarea","name":"__generic19","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"If other, please explain here"}

Please describe your audience.

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Presentation Topic

Which service are you interested in?

Keynote Presentation Educational Workshop Professional Development Staff Education Interactive Training Panel Discussion Podcast Guest Webinar Customized Presentation Other{"type":"checkbox","name":"__generic21","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Keynote Presentation\nEducational Workshop\nProfessional Development\nStaff Education\nInteractive Training\nPanel Discussion\nPodcast Guest\nWebinar\nCustomized Presentation\nOther"}

{"type":"textarea","name":"__generic22","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"If other, please explain here"}

Preferred Topic(s)

Leadership Coaching Life Transitions Healthcare Navigation Professional Development Medical Advocacy Wellness Stress Management Burnout Prevention Work-Life Balance Disability Awareness Brain Injury Executive Function Caregiving Accessibility Trauma-Informed Practices Communication Advocacy Professional Growth Other{"type":"checkbox","name":"__generic23","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Leadership\nCoaching\nLife Transitions\nHealthcare Navigation\nProfessional Development\nMedical Advocacy\nWellness\nStress Management\nBurnout Prevention\nWork-Life Balance\nDisability Awareness\nBrain Injury\nExecutive Function\nCaregiving\nAccessibility\nTrauma-Informed Practices\nCommunication\nAdvocacy\nProfessional Growth\nOther"}

{"type":"textarea","name":"__generic24","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"If other, please explain here"}

Event Goals

What would you like participants to learn or gain from this presentation?

{"type":"textarea","name":"__generic25","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Virtual Platform

Which platform will be used?

Zoom Microsoft Teams Google Meet Webex We are open to whatever works for the speaker Other{"type":"checkbox","name":"__generic26","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Zoom\nMicrosoft Teams\nGoogle Meet\nWebex\nWe are open to whatever works for the speaker\nOther"}

{"type":"textarea","name":"__generic27","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"If other, please explain here"}

Will technical support be provided?

Yes No{"type":"checkbox","name":"__generic28","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}

Recording

Will the presentation be recorded?

Yes No Unsure{"type":"checkbox","name":"__generic29","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo \nUnsure"}

If yes, how will the recording be used?

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Budget

Is there a speaker budget?

Yes No Unsure Budget Range (optional){"type":"checkbox","name":"__generic31","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo\nUnsure\nBudget Range (optional)"}

{"type":"textarea","name":"__generic32","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"Enter budget information here."}

Additional Requests

Would you like information regarding:

Educational Resources Customized Workbooks Workshop Follow-Up Workshop Coaching Services Consulting Services Vital Ability Academy Additional Speaking Topics Customized Topic Other{"type":"checkbox","name":"__generic33","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Educational Resources\nCustomized Workbooks\nWorkshop\nFollow-Up Workshop\nCoaching Services\nConsulting Services\nVital Ability Academy\nAdditional Speaking Topics\nCustomized Topic\nOther"}

{"type":"textarea","name":"__generic34","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"If other, please explain here"}

Additional Information

Please share anything else that would help us better understand your event

{"type":"textarea","name":"__generic35","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"More information is always better than less to help us meet your needs."}

Agreement

I understand that submitting this form is a request only and does not guarantee speaker availability.

I understand that speaking engagements are confirmed only after mutual agreement regarding presentation details, fees (if applicable), and scheduling.

☐ I Agree

Signature (if applicable) {"type":"signature","name":"__signature","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter your signature.","height":150}

Date {"type":"text","name":"__generic36","width":25,"value":"","size":"Normal","validation":"DV","validationMessage":"Please fill in this item.","placeholder":"00/00/0000"}

Thank You

Thank you for considering Vital Ability LLC.

We appreciate the opportunity to learn more about your event and look forward to discussing how we may help create an engaging and meaningful educational experience for your audience.

We are honored you have reached out to us and will be getting back to you as soon as possible.

You can reach us for additional questions at:

myvitalability@gmail.com

616-730-1204

Support. Transition. Transform.

Sincerely,

Caren Robinson - Founder

PERSONAL DATA
The provision of personal data (“Data”) in this form is voluntary and will be used to utilize the Career and Volunteer Interest Form or to provide additional information about requested items. If you fail to supply the data requested herein, we may be unable to process your application for information, and you will be unable to submit this form.

The data may also be used for any of the following purposes:

providing program services;
performing administrative matters, communication and liaison concerning the programs, Vital Ability LLC, and their respective associates or affiliates;
promoting program and events;
any other legitimate purposes as may be required, authorized or permitted by law

The data may be used, stored, disclosed, and transferred by Vital Ability LLC to its associates and affiliates, any government department or regulatory body if required by law, and any individuals/organizations associated with the programs herein, including its agents and contractors, for the purposes specified above.

If you would like to request access to and/or correction of the data retained by us, please e-mail us at myvitalability@gmail.com. Any requests for access to and correction of information will be dealt with as promptly as possible.