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Pre-Program Questionnaire PDF

Please answer the following questions completely so I can customize my presentation for your group. Feel free to have others involved in planning contribute.

Contact Information

Your E-Mail Address: (required)
Complete Name of Facility or Group:
Website Address:
Contact Person and Title:
Address:
City:
State:
Zip Code:
Best time to reach:
Phone Numbers (work):
Fax:
Cell:
Evening or Emergency Contact:

Program Information

Kathy's Program #1 Topic/Title:
Date: / /
Time: to
Break Times(if applicable):
Kathy's Program #2 Topic/Title:
Date: / /
Time: to
Break Times(if applicable):

Meeting Information

Meeting Location:
Meeting Address:
Meeting City:
Meeting State:
Meeting Zip Code:

Transportation Information

Closest Airport:
Number of miles from airport to meeting site and hotel:
Will someone be meeting me? If so, please provide the name, location and time:
Specific directions to meeting location and contact person at the meeting site:
What form of transportation will be provided to the meeting site?

Hotel Information

Hotel Name(if applicable):
Hotel Address(if applicable):
Hotel City(if applicable):
Hotel State(if applicable):
Hotel Zip Code(if applicable):
Hotel Phone Number(if applicable):
Reservation Confirmation Number(if applicable):
Will the hotel be directly billed to you (client)?

Meeting Information

What form of ground transportation will be used to and from the hotel and airport?
What is the conference theme?
Who will be introducing me? (Please provide name, title, and e-mail address):
What are your goals and objectives for my portion of your program?
How will you know if I am successful? (Please define a target)
How can I assist you in meeting these objectives? What 2 or 3 points would you like made?
Would you like worksheet and/or bulletin board piece originals to copy? Yes
No
Page Number Limit:
Preferred Format:
Will you require CEU information? Yes
No
CEU information due date:
Who will be attending this presentation? (job titles - age range - gender mix - deparments)
How large will the group be?
Describe the room and stage/seating setup for the meeting:
Who will be the A.V. contact person?
What is the A.V. contact person's number?
When is the A.V. setup and sound check?
What is the general attitude of the group?
Are there any areas of discussion you prefer be avoided or sensitive issues of which I should be aware?
What is the mission of your company or group?
What are the current stressors or challenges you are facing?
What is special or unique about the people in this audience (e.g., languages, disabilities)?
What is happening before and after my presentation:
Please list other speakers, their topics, and their time slots:

Product Information


PRODUCTS WILL NOT BE SOLD FROM THE PLATFORM

Would you like me to have products available for sale? Yes
No
Would you like to purchase products / books for prior to the event? Special pricing is available for pre-event sales. Yes
No
How would you like me to handle the sale of products?



I want to be certain your group has a great day. Please provide any other information you feel would be helpful in customizing this presentation.
Buzzwords:
Pet Peeves:
Inside Jokes:
Audience members you would like mentioned:
Names and phone numbers of anyone you'd like me to talk with for input:
Is there anything else I can do to ensure the success of your meeting?
Provide a Book Signing?
Meet and Greet Attendees?
Attend a Reception?
Share Meal or Banquet with Attendees?
Please send copies of program brochures, agendas, or other promotional materials so my presentation is consistent with your advertising. I'd also appreciate any newsletters, articles or information on your group/facility you feel would be helpful in my presentation.
Information can be sent to:

Kathleen Passanisi
New Perspectives
9 Stone Falcon Court
Lake Saint Louis, MO 63367

OR

Fax: 636-561-2520

OR

E-Mail: kathleen@kathleenpassanisi.com