Please submit your request for a speaker at least two weeks in advance of the date of the event, and allow three business days for a response. Someone from The WellHouse team will reach out to you!

REQUEST A SPEAKER

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Event Name

Organization Hosting Event

Event Location Address

Event Start Date

MM

DD

YYYY

Event Start Time

Hour

Minute

Second

Event End Date

MM

DD

YYYY

Event End Time

Hour

Minute

Second

Date Speaker Would Arrive

MM

DD

YYYY

Time Speaker Would Arrive

Hour

Minute

Second

Date Speaker Would Depart

MM

DD

YYYY

Time Speaker Would Depart

Hour

Minute

Second

Number of People Attending

Description of Audience Members

Event Agenda

Speaking Duration

What topic(s) would you like the speaker to address?

May we bring ShopWell items to sell?

Are you able to cover travel/mileage expenses of the speaker?

Are you able to provide a contribution to The WellHouse as a speaker honorarium (suggested, not required, amount of $250-$1000)?