Sponsor
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Please provide the name of the organization, inviting Dr. Legha, as well as street address, city, state, and zip.
Sponsor Email Address
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Sponsor Phone Number
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Sponsor/Event Website
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Are you considering other speakers for the event?
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Yes
No
How did you hear about Dr. Legha?
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Virtual or In-Person Event
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Virtual
In-Person
Event Description/Itinerary
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Please include any pertinent information related to the event and including all duties of the speaker during this engagement (example: Lecture, class visit, lunch with sponsors).
Type of Speaking Engagement
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Please check all that apply
Time allotted for speaking engagement
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Please list the exact time frame or number of minutes Dr. Legha will be expected to prepare for (Example: 5 minute introduction, 45 minute lecture, 10 minute discussion)
Are you hoping to have a planning call with the Dr. Legha?
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Yes
No
Do you plan to have a technology run-through with Dr. Legha?
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Yes
No
If you are requesting a planning call OR a technology run-through session, please specify date(s) and time(s) of availability.
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Please specify exactly how much time you would like to spend with Dr. Legha.
Instructions for Event Platform
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Honorarium
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Process for obtaining honorarium
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Provide contact person, paperwork that must be completed, and timeline for receiving honorarium.
Requested Topic
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Number of Expected Attendees
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Audience Profile
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Please specify whether the audience is students, health professionals, community members, or other. If the topic pertains to antiracism, please specify whether the audience is majority-white or not AND describe which antiracist journey zone (see image below) best describes them. This information helps Dr. Legha curate the content and determine the degree of minority taxation involved with giving the talk.
Number of Expected Attendees
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Public Event
Yes
No
Speaking Attire
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