Speaker Request Form (CEA)

Please complete the form below to request Shawnta Jackson to be a part of your event.

Thank you for sharing your interest in booking our Founder & Chief Executive Associate, Shawnta Jackson, for your next speaking engagement. Please complete the speaker request form and we will contact you shortly. If you have additional questions or need assistance, please email us at info@causeengagement.com or call 240-560-3711.

Question Title

* 1. Your Contact Information

Name

Company/Org

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Expected Audience Size

Question Title

* 3. Which best describes the audience? (Check all that apply)

Healthcare

Public Health

Academia/Research

Nonprofit

Government

Middle/High School Students

College/University Students

Community Members

Advisory Board/Coalition

Corporate

Other (please specify)

Question Title

* 4. Projected Budget for Securing Services

Question Title

* 5. Name of the Event

Question Title

* 6. Event Theme / Topic

Question Title

* 7. Event Format

Keynote Address

Workshop

Training

Group Facilitation

Webinar

Other (please specify)

Question Title

* 8. Event Date(s) of Interest

Question Title

* 9. Event Start & End Times

Question Title

* 10. Event Location

Question Title

* 11. Nearest Airport(s) to Event Location

Question Title

* 12. Do you intend to record or live stream this event?

Yes