Speaker Invitation- Rachel Hardeman

Sponsor *

(Provide the name of host organization, street address, city state, zip code)

Sponsor/ Event Website *

Are you considering other speakers for the event *

How did you hear about the speaker?

Virtual or In-Person Event *

Event Date(s) *

Please list the EXACT date that you wish to have Dr. Hardeman speak.

Event Description/Itinerary *

Please include any pertinent information related to the event including all duties of the speaker during this engagement (example: Lecture, class visit, lunch with sponsors) Please note that additional events will not be accommodated if not listed here.

Event Time *

Event Time Zone *

Event Location

Please list the building and address of the in-person event

Type of Speaking Engagement *

Select all that apply to the engagement

Time alloted for speaking engagement *

Please list the exact time frame or number of minutes the speaker will be expected to prepare for. (Example: 45 min lecture)

Length of Q&A *

Presentation Topic *

Structural Racism and Supporting Black Lives - The Role of Health Professionals
“Momma!”: An Exploration of the Intersections of Reproductive Justice and Police Violence
Black Babies Matter: Physician-Patient Racial Concordance and Disparities in Birthing Mortality for Newborns
"We have run out of time": Antiracist Approaches to Data & Measurement for Health Equity
Black Reproductive Health: Getting at the Root Cause of Inequity
Other

Please list the topic you want Rachel to discuss

Please note that the curation of a new presentation is subject to Dr. Hardeman's availability.

Is a slide presentation required? *

YES
NO

DUE DATE OF SLIDE PRESENTATION *

Is a conflict of interest form required? *

YES
NO

DUE DATE OF COI FORM *

Do you plan to submit this presentation for continuing education credits? (CEU) *

YES
NO

Do you wish to have a planning meeting *

YES
NO

Please note that planning meetings will be attended by a staff member of Dr. Hardeman's center.

Please describe your organization's COVID-19 Protocols

Closest Airport to the Event Location *

Please include name of airport, distance from the event location, and travel time to the event location

Distance of Airport to the Event Location (Mileage and Time) *

Please include distance from the event location in mileage and time.

Event Platform

Do you have instructions for the use of the event platform?

Do you plan to have a technology run-through? *

Please note that Dr. Hardeman will ONLY attend tech run throughs if she has no experience with the platform

Date/Time of Tech Run Through *

Please note that Dr. Hardeman can only accommodate tech checks if the date/ time are listed on the form.

Honorarium *

Will your organization cover travel expenses? *

Yes
No

Total amount your organization will reimburse for travel expenses *

If your organization has special requirements for travel, please list them here.

Example: The organization will only reimburse coach flights.

Audience Profile *

Number of Expected Attendees *

Public Event *

YES
NO

Anticipated Book Sales

If Applicable

Speaker Attire (mark one): *

Casual
Business Casual
Business
Academic Regalia

Sponsor Contact Information

Sponsor Contact Name *

Title *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Signature

Name and Title of Individual Responsible for Signing Contract *

A formal contract will be created if the speaker accepts the invitation. This is NOT a contract *

Signature

Date