Speaker Engagement Form
Matthew Melmed, Executive Director
Your name:
*
First Name
Last Name
Your email:
*
example@example.com
Your phone:
*
-
Area Code
Phone Number
Your organization name:
*
Your title:
*
Event name:
*
Event type (please select all that apply):
*
Breakout session
Briefing
Conference
Panel
Presentation
Social media event (Facebook Live, Tweetchat, Google Hangout, etc.)
Training
Webinar
What is ZERO TO THREE's role in the event (please select all that apply)?
*
ZERO TO THREE is hosting or cohosting the event
ZERO TO THREE is sponsoring or cosponsoring the event
I am attending the event
I am staffing the event
Someone else at ZERO TO THREE is staffing the event
I am speaking/presenting at the event
Someone else at ZERO TO THREE is speaking/presenting at the event
What is ZERO TO THREE's role in the event (please select all that apply):
*
ZERO TO THREE is hosting or cohosting the event
ZERO TO THREE is sponsoring or cosponsoring the event
A ZERO TO THREE staff member or contractor has committed to speaking/presenting at the event
A ZERO TO THREE staff member or contractor has been invited to speak/present at the event
Event Description (include theme, desired purpose/outcome):
*
Event date:
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Month
-
Day
Year
Date
Start time:
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
End time:
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:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What time zone will the event take place in?
Eastern Time
Central Time
Mountain Time
Pacific Time
Event format:
In Person
Virtual
Is there a dedicated call-in line/address for speakers and staff? If so, is that information available?
Event address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
Primary event contact information
Are you the primary event contact for purposes of coordinating ZERO TO THREE's engagement?
*
Yes
No
Primary contact name:
*
First Name
Last Name
Primary contact organization:
*
Primary contact title:
*
Primary contact email:
*
example@example.com
Primary contact phone number?
*
-
Area Code
Phone Number
Is the primary event contact also the day-of contact?
*
Yes
No
Day-of event contact name:
*
First Name
Last Name
Day-of event contact organization:
*
Day-of event contact title:
*
Day-of contact email:
*
example@example.com
Day-of event contact phone:
*
-
Area Code
Phone Number
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Speaker's role
Type of presentation:
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Brief remarks
Introduction
Keynote
Panelist
Start time for speaker's remarks:
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1
2
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6
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10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
End time for speaker's remarks:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Requested arrival time for speaker:
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1
2
3
4
5
6
7
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Requested themes or topics speaker should address:
*
Who will introduce the speaker (name, title, organization)?
*
Other invited guest speakers/panelists:
*
Will a runthrough of the event be held?
Can the speaker's laptop be easily connected to the a/v system? If not, please provide a/v requirements.
Will transportation be provided? If so, please include details.
Will hotel accommodations be provided for the attendee? If so, please include details.
Will the speaker receive an honorarium? If, so please indicate amount.
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Audience
Number expected to attend event:
*
Number expected to attend session:
Description of Audience (please be as specific as possible (e.g. Pre-K teachers, funders organizations, elected officials, etc.):
*
Are there notable elected officials, organization leaders, other attendees who we should recognize (include name and title)?
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Media and promotion
Will there be media outreach of this event (please select all that apply)?
*
Event is closed to press
Event is open to press and organizers will do outreach
Event is open to press and ZERO TO THREE will do outreach
Event is open to the press and organizer would like to have a conversation with the ZERO TO THREE media team to coordinate outreach
Event is open to the press, but doesn't require outreach
Press contact name:
First Name
Last Name
Press contact email:
example@example.com
Press contact phone:
-
Area Code
Phone Number
Primary website that will be used to promote this event:
Will the event be live streamed?
Yes
No
What is the live stream link?
*
Will the event be recorded?
Yes
No
If yes, will the recording be made available to the public after the event?
Yes
No
Will there be an official event photographer?
Yes
No
What social media and hashtags (Twitter, Facebook), etc.) will be used to promote this event?
How else will the event be promoted?
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ZERO TO THREE collateral
Will the event's host organization share ZERO TO THREE materials with attendees?
Yes
No
How will materials shared digitally?
In person
Digitally
If yes, how will materials be shared digitally?
What ZERO TO THREE materials will/should be shared at the event?
When must ZERO TO THREE materials be submitted by?
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Month
-
Day
Year
Date
Will ZERO TO THREE be responsible for shipping materials to the event?
Yes
No
Shipping address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping contact:
*
First Name
Last Name
Shipping contact phone:
*
-
Area Code
Phone Number
Shipping contact email:
*
example@example.com
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Other information
Please upload relevant documents (agenda, press release, speaker bios, etc.):
Browse Files
Cancel
of
Browse Files
Cancel
of
Browse Files
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of
Is there any other information that would be helpful for us to know?
Do you have any specific requests from the ZERO TO THREE communications team?
Submit
Should be Empty: