* Your Name:

* Your Email:

* Organization name:

* Name of Event:

* Address of Event:

Event Coordinator:

Position/Title:

* Phone number:

* Speaking Date:

* Speaking Time:

* What Best Describes Your Event?

Church or MinistryNon-ProfitBusiness or OrganizationFaith-Based Private School/UniversityPublic School/UniversityPrivate School/UniversitySummit or ConferenceDiversity/Inclusion EventOther:

If Other, please describe:

Do you have a specific theme or topic?

What is the age group attending?

Is your event... (check all that apply)

HearingDeaf & Hard-of-Hearing

If Deaf & Hard-of-Hearing... (check all that apply)

Spoken LanguageASL

Will you be providing... (check all that apply)

IntepretersCART (Real Time Captioning)

*What is your hope for Emma Faye’s role at your event?

Speaking OnlyTeaching & AwarenessWorship/Music Interpreter (Emma Faye is deaf and cannot interpret for others)Teach Others Limited ASLOther:

If Other, please describe:

Do you want to leave time for Q & A? If so, how many minutes?

* How many people are you expecting at this event?

* Dress Code:

* What is your budget?

Is there anything that would be helpful for us to know about the people attending your event? (Age group, spiritual background, things to be sensitive to, aware of, etc.?)

Please list any other speakers (if applicable) participating in the event:

* How long would you like her performance to be? Explain: (ie: 30 minute speaking, 10 minute Q&A )

If a Diversity/Inclusion event, are you looking for a PPT presentation? (please have a AV system with remote in place. PPT will be sent prior to event)

What day would Emma Faye need to arrive?

What time would she need to arrive on the day listed above?

What day would Emma Faye’s role conclude?

What time would Emma Faye’s role conclude on the day listed above?

Can merchandise, if any, be allowed to be sold at your event?

What is the closet airport? Southwest Airline is preferred, if not available American.

Please list three hotels nearby? Please use a national chains such as a Marriott Courtyard, Hilton Garden Inn, Hampton Inn. Note: When booking, Emma Faye will need a deaf accessible room.

* Whenever possible, we like for Emma Faye to be able to travel with a hearing assistant. Would you be able to cover the travel costs of one additional person to accompany Emma Faye?

YesNo