Speaker Request FormKamilah Thomas, MSW, LCSW-S Please complete the form below Name * First Name Last Name Organization/Company Name * Phone Number * Email * Name of Event * Address/Location of Event * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Event * MM DD YYYY Time of Event * Hour Minute Second AM PM Expected Number of Attendees * Speaker Budget for Event * $0 - $500 $500 - $1,000 $1,500 - $3,000 How long would you like Kamilah to speak? * In what role would you like Kamilah to serve? * Keynote Speaker Workshop Facilitator Trainer Panelist Will Kamilah be able to promote her services or products? * Yes No Let's Discuss Will travel accommodations be needed? Please keep in mind that Kamilah resides in Houston, TX. * Yes No How did you hear about Kamilah? * Facebook Instagram LinkedIn Internet Word of Mouth Other (Please Specify) Overview of Audience (career professionals, entrepreneurs, students, etc.): * What goals or objectives do you want the presentation to address? * How do you want the audience to feel after the presentation (inspired, informed, educated, and/or motivated): * Thank you! We will respond to your inquiry shortly.
