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Contact Information

Full Name

Organization / Company

Email Address

Phone Number

Your Role/Title

Event Details

Event Name

Event Date

Event Location

Time of Keynote (if known)

Length of Presentation Requested

Type of Event

Theme or Focus of the Event

Expected Audience Size

Audience Demographics

Other Speakers (if applicable)

Speaker Engagement Details

Type of Engagement

Keynote Panel Fireside Chat Workshop Other (please describe)

Requested Topic(s) or Themes

How would you like Chad to tailor his message to your audience or event theme?

Preferred Format

In-person Virtual Hybrid

Logistics & Support

Will travel & accommodation be covered?

Yes No Let’s discuss

Is there an honorarium or speaker fee budget?

Will the session be recorded or live-streamed?

AV/Technical Requirements or Restrictions (if known)

On-site or Primary Contact Person

Final Notes

Anything else you’d like Chad to know?

Are you Liberated? Have you created your life by-design, or are you merely tolerating a life by-default?

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