Form to Request Speaker Engagement or LifeLine Participation in Event

    Title of Event (required)

    Who is the primary contact for the planning of this event?

    Name (required)

    Position (required)

    Phone number 1 (required)

    Phone number 2

    Email (required)

    What is the name of the church, organization, school, etc. that you represent? (required)

    Where are you located?

    Address (required)

    City, State, Zip (required)

    What type of participation are you requesting? (required)

    What date/dates are you considering for this event? (required)

    Do you have a specific existing workshop(s) in mind?
    Refer to LifeLine Workshop Topic List by clicking here then please list (required)

    If the topic you were looking for is not listed, on what topic will you need someone to speak ? (required)

    If you would like for LifeLine to host a booth at your event, please share specific details

    Will this booth be indoors or outdoors? (required)

    Will a table be provided? (required)

    Would you like information about Special Needs Ministry? (required)

    Would you like information about Special Education topics? (required)

    How many attendees are expected? (required)

    Where will the event be held? (required)

    Thank you for considering LifeLine to speak at or participate in your event. We will be in touch as soon as possible.