Speaker Request Form

Organization Info

Host Organization(Required)

Organization Address (for invoicing purposes)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your organization a KLC Leadership Transformation (LTG) Grant Partner?

Yes

No

Is your organization a KLC Community Leadership Program (CLP) Partner?

Yes

No

Primary Contact Info

Name(Required)

First Last

Email(Required)

Phone(Required)

Job Title

Engagement Info

Describe the Event (conference, training, workshop, retreat, panel discussion etc.)(Required)

If it is a multiple day or larger event that the Speaker will be joining please include all dates & times for our reference:

DATE Requesting Speaker(Required)

Speaker START time(Required)

:

Speaker END time(Required)

:

Location of Engagement(Required)

Address of Engagement(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Estimate the number of attendees:(Required)

Please share any information you have about the demographic information of the audience. (age, race, gender, positions, locations)(Required)

Will there be any live streaming, virtual attendees, or press present? Please explain.

Is there anything else that would be helpful for KLC to know as we consider the request?

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KANSAS LEADERSHIP CENTER

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