SPEAKING & WORKSHOP INQUIRY FORM

Thank you for your interest in booking me for your event. Please provide the following information to help me understand your needs and determine availability.

Contact Information

First name:*

Last name:*

Organization:

Job Title:

Email:*

Phone

Preferred Contact Method:

Phone

Event Details

Event Name:

Event Type:

Event Date:*

Flexible Dates:

Yes

If flexible, please specify alternative dates:

Select a Service*

Event Location:

Expected Audience Size:

Target Audience:

SESSION DETAILS

Type of Presentation Desired: [Checkboxes - select all that apply]

Keynote Speech (60-90 minutes)

Half-Day Workshop (3-4 hours)

Full-Day Workshop (6-8 hours)

Panel Participation

Moderated Discussion

Series of Sessions

Other (please specify)

Preferred Topic(s): [Checkboxes - select all that apply]

Shatter the Glass Ceiling Within (Imposter Syndrome & Resilience)

Turning Vision into Action (Strategy & Execution)

The Power of Change (Navigating Transitions)

Confidence & Executive Presence

The Transition Toolkit (Career Navigation)

From Burnout to Boundaries (Sustainable Success)

Custom Topic (please describe below)

If custom topic, please describe:

What specific outcomes are you hoping to achieve from My presentation?

ADDITIONAL INFORMATION

Budget Range:

How did you hear about me?

Any additional information that would help me understand your event needs:

Form submissions are typically responded to within 1-2 business days. For urgent inquiries, please email Jessica@JCNewbeginnings.com.

Required fields are marked with an asterisk ().*

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