Polka Dot Powerhouse Four Rivers Chapter - Speaker Application

Full Name *

Email *

Phone *

Topic/Catchy Title of your talk

Brief description of your talk

3 things attendees can expect to learn

In lieu of reading your 1 minute Bio before you speak, these three questions will be asked so the audience gets to know you better. 1) Personal-What brings you the most joy outside of your work? 2) Professional-What inspired you to do what you do? 3)Polka Dot-Which of the 3 has impacted you the most, connection, collaboration or celebration?

Ice Breaker Question (asked during introduction time in meeting)

Link to Your Website

Social Media Links (for connection and tagging)

Have you recently spoke for a chapter meeting? Name of the chapter and when?

As a speaker, what are you hoping to receive from sharing your story and expertise with the attendees?

Please upload your Headshot

Upload the Signed Media Release *

I acknowledge that my talk and presentation is not to include a sales or product pitch. No logo or contact on slide presentation. I agree to a social media post, will share the post, and invite my social media following to attend

I agree