The Black Brain Campaign Event Request Form
Thank you for your interest in having the Black Brain Campaign appear at your event. Online submission of this form is required for all requests and must be received at least 2 weeks prior to your event. The purpose of this form is to collect as much information as possible in advance so we can be prepared to help you have a great event! Please fill out this logistics form with as much detail as possible. We really appreciate your time completing this form. Please note, completing this form is not a confirmation for attending your event. If you have any questions, please contact Jamillah Byrd, Event Coordinator, via email at email@example.com by phone at (215) 778-9716
Enter your contact information
Please enter a valid phone number.
Organization (write N/A if applicable)
Are you a member of the media
Founder & Executive Director, Farida E. Boyer
Chief Medical Officer, Dr. Taliba Foster
Clinical Coordinator, Kevana Nixon
Mental Health Therapist
Date of event
Time of Event
Type of Event
Time of Arrival
Length of time BBC is expected to speak (ex: 20 minutes Resources)
Location (if applicable)
Address (if applicable)
Please select the type of event
Guest Speaker (TV, Radio, Podcast)
Guest Speaker (Company, Community event, etc.)
Please Choose any of the following to help us with the theme for your event.
BBC Services (Mental Health)
BBC LEAP ( Licensure Assistance)
Mental Health Training
Education & Training for Clinicians
Mental Health Resources
Do you need any of this deliverables from us?
Bio (please note length limitations below)
Additional photos (please specify below)
Video (please specify)
Additional information on the chosen deliverables above:
Thank you, just a few more questions please...
Do you have any attachments you'd like to add?
Will share at a later time.
Drag and drop files here
Choose a file
Do you have a budget?
If available, please copy and paste a summary/agenda of your event (if you have not added an attachment)
Anything else we should know?
Thanks! Last question to help us with our processes
Was this form easy or difficult to complete?
Neither easy nor difficult
Should be Empty: