Thank you for considering Dr. Regina Robinson for your upcoming event.

Please complete the speaking inquiry below to tell us more about your organization, audience, event goals, and requested engagement.

Our team will review your submission, confirm availability, and determine the appropriate next steps.

Please note: Submission of this form does not confirm or reserve your event date.

Speaking Inquiry

First Name *

Last Name *

Phone *

Email *

Job Title / Role

Organization / School / Company Name *

Organization Website

Event Information

Event Name / Theme *

Event Date *

Is your event date flexible? *

Yes

Possibly

Event Format *

In Person

Virtual

Hybrid

Event Location *

Estimated Number of Attendees *

What type of organization are you representing? *

Select an option

Audience & Event Goals

Who will be in the audience? *

What is the purpose of the event and what do you want participants to walk away knowing, feeling, or prepared to do? *

Speaking Request

In what capacity are you interested in having Dr. Regina participate? *

Select an option

Which area would you like Dr. Regina to address? *

Select an option

Investment & Booking

What is your budget for this speaking engagement? *

For an in person engagement, has your organization budgeted separately for required travel and lodging? *

Yes

Not Applicable

Need to Discuss

Decision Making

Are you involved in making the final speaker selection? *

Yes, I am the decision maker

I am part of the decision making team

When do you anticipate selecting your speaker? *

Select an option

Final Details

How did you hear about Dr. Regina Robinson?

Select an option

Is there anything else you would like our team to know about your event?