Speaking Request Form – One-Eighty Counseling and Education

Church / Organization Information
Name of your church or organization*
Denomination (if applicable)
Church / Organization Address*
Street Address Address Line 2 City State ZIP Code
Church / Organization Phone*
Church / Organization Fax
Church / Organization Website
Doctrinal statement of your church/organization (if you have never before hosted Dr. Scott):
Venue*
Venue Address*
Street Address Address Line 2 City State ZIP Code
Venue Phone*
Pastor or Primary Contact for this Event*
First Last
Pastor or Primary Contact Home Phone*
Pastor or Primary Contact Cell Phone*
Pastor or Primary Contact Email*
Secondary Contact
First Last
Secondary Contact Home Phone
Secondary Contact Home Cell
Pastor or Primary Contact Email
First Choice for Event Date*
Date Format: MM slash DD slash YYYY
Second Choice for Event Date
Date Format: MM slash DD slash YYYY
Nature of the event (i.e. conference, men's retreat, pastors' conference, Sunday worship service, etc.).*
Number and length of times Dr. Scott is to speak, possible topic(s) and possible schedule (Please refer to the speaking topics page, but note that these details may be discussed and finalized in future correspondence).*
Will PowerPoint capability and equipment be present?*
(Dr. Scott prefers to use PowerPoint and requests that he be able to toggle the slides himself as well as have a laptop or screen in front of him.)
- Yes
- No
Will there be a large whiteboard available?*
- Yes
- No
Will there be any other speakers at this event?*
- Yes
- No
Please list all other speakers.
Will there be music or other components included in the event?*
- Yes
- No
Please describe.
What is the approximate anticipated attendance of this event?*
Who is the target audience?*
Into which airport will Dr. Scott fly, and how far is the airport from the event?*
Phone
This field is for validation purposes and should be left unchanged.

Church / Organization Information