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*

Second Choice for Event Date

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?*

Name

This field is for validation purposes and should be left unchanged.