If you'd like Tim Elmore to speak at your event, simply fill out this form. We will contact you shortly after we receive it.

Fields with the * symbol are required to be filled in.

General Information
Contact Person *:
Title:
Sponsoring Group:
Address:	street and suite # city state zip
Phone *:
Fax:
Email *:
Event Information
Possible Event Dates *:
Main Goal/Theme of Event *:
Is this a closed event to your group?	Yes No
Expected Size & Demographics of Group
Executive Leadership
Staff
Volunteers
Other:
Total:
Event Logistics
Event Location (city, state, venue) *:
Will PowerPoint be available?	Yes No
Will a VCR be available?	Yes No
Will an LCD projector be available?	Yes No
Number of times speaker will present:
Amount of Financial Renumeration (we charge a $75 incidental fee in addition to any travel expenses incurred)
Honorarium *:
Travel Expenses (airfare, car rental, lodging, meals, etc.):
Will Growing Leaders product sales be allowed during the event?	Yes No
Are there any restrictions on product sales at this event?	Yes No
Growing Leaders (Tim's non-profit organization) is interested in partnering with organizations for on-going leadership development of students through mentoring groups, resources, etc. Would you be willing to discuss partnering with Growing Leaders toward this shared leadership development goal? Yes No