Name *
Just your legal first and last name.
Please write out your name as you would like it to officially appear in our marketing materials, web, Youtube, etc. Example: "Brandon Keith Weber, PhD."
Mobile Number *
Mobile Number
Mobile number to reach you at.
Preferred Number
Preferred Number
If there is a number that you prefer us to reach you at, we will use this (but we will still need your mobile number above).
We will use either skype or Google Hangout at some point with you.
We will use either skype or Google Hangout at some point with you.
Only if you want to share it.
Only if you want to share.
This is the bio that we will be using for marketing, program, and eventually your video bio, etc. This will help our viewer understand why they should listen to you. It's also good to tell us something about your passions, rather than just a laundry list of accomplishments. Don't worry, there will be time to adjust and refine.
Why do you do what you do? Why do you want to share your idea? This will help our team to understand you and better assist you in shaping your talk.
In three sentences or less, please tell us the idea that you would like to share from our stage. Don't worry, there will be time to change or refine. We recommend a more focused message over a broad one for the sake of both time and impact.
It often helps to think about your talk as an answer to a question or a problem. Please pose this in the form of a question.
This is just a working title. There will be time to change.
If you plan on bringing a guest(s), please let us know.
We only guarantee 1 guest pass to the event, but we will try to accommodate more, if needed.
Any Questions or Concerns that you might have that our team might help to address?