Media and PR - Empowered Potential

Karen Phillips wants to tailor her presentation to meet your needs. Please fill in the answers to the questions below, skipping over any that may not apply.This questionnaire is used in preparing Karen's presentation for your event. To ensure that the program is tailored to meet your needs, please submit this form one month prior to your event.

Easy Options:

Simply fill out this form and submit it online
Or…if you wish to discuss these with Karen by telephone, call (702) 269-7979 to set up a meeting by phone.

* Indicates required fields

Full Name*:

Company/Organization:

Email Address*:

Address Line 1:	Suite/Apt #:

City:	State:	Zip:

Country:

Phone # (including area code)*:
Ext

Alternate Phone # (including area code):
Ext.

Web Site:

Best Time to Call*:

Please describe your event:

What is the date and time of your event?

Month	Day	Year	Time

Event Theme

Closest Airport

Estimated driving time from the airport to event location:

Will you provide transportation to and from the airport?

Additional Comments:

Lodging Information:

Name:
Company:
Address:

City:	State: Zip:

Hotel phone number and confirmation #:

* Event Location:

Name:
Company:
Address:

City:	State: Zip:

* We would like Karen to do the following while she is with us (check all that apply):

Conference Keynote

Conference Closing

School Assembly

Banquet

Commencement Address

Breakout Session(s)

Advisor's Session

Staff Development Program

Other, please specify

* The main presentation will take place in an:

	Auditorium
	Gymnasium
	Cafeteria
	Lecture Hall
	Hotel Ballroom
	Hotel Conference Room
	Classroom
	Large Group Instruction Room
	Multi-Function Room
	Other, please specify:

Audience Size:

The audience will be seated: (check all that apply):

	in fixed seats
	in bleachers
	at round tables
	in portable chairs
	Other, please specify:

Type of Sound System:

	Native to the room
	An outside sound system will be brought in
	Other, please specify:

What time should Karen arrive?

Schedule for the day (please provide as much detail as possible):