Speaking Request Form

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Thank you for considering Jackie as a speaker for your event. Please complete this questionnaire to let her know about your group and the event you are planning.

The more information you provide, the better Jackie can determine the best way to meet your specific needs and customize her presentation. Please fill out the form as completely as possible and be sure to ask any questions you need answered in the last box on the form. Thank you for your time and information.

Please provide the following information so that I may contact you
(required fields are in yellow):

Contact Name:
Title:
Organization:
Department:
Email Address:
Phone Number:
Fax Number:
Preferred Method of Contact: Email Phone Either
Address:
City:
State:	Zip Code:

Title(s) of Presentation(s) Requested: Creating Connections A Life of Gratitude Conversation Awareness Intuition & Leadership Your Body Talks & the World Listens Motivating, Heathy Workplace Community Coaching Extreme Career Makeover with Patience Create Balance Live for Today! Wellness Mindfulness Team/Trust Building Your Health/Life Other Customized Topic

Date(s) you want presentation:
Approximate time of presentation:
Approximate Audience Size:
Presentation Location:
Who is the audience?
What is the theme and purpose of your event?
What are the specific objectives for the presentation?
Are there any sensitive issues that should be avoided?
What are three main things that should be known about your group before addressing them?
What significant events have occurred in your organization or group in the past year?
What takes place immediately before, during and after this presentation?
Please list below the names and titles of people in your organization with whom we should be familiar:
Questions? Comments? Additional Information? Please let me know: Please check if you are an animal. Yes No

Privacy Policy: It is our policy to respect your privacy and you have our guarantee that the information you provide on this page will not be given, sold or otherwise disclosed by Whole Life Visions or its affiliates, employees or contractors, to any third party.

Jackie Bredl-Dietrich, CHES, PCC
Life & Business Coach, Speaker, Consultant & Author
P.O. Box 1101, Wisconsin Rapids, WI 54495
715-421-4700
Jackie@WholeLifeVisions.com

Receive event updates & info about what's on the horizon

Receive event updates & info
about what's on the horizon