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 events@theblackbraincampaign.org by phone at (215) 778-9716
Enter your contact information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Organization (write N/A if applicable)
Are you a member of the media
Yes
No
Speaker Requested
Founder & Executive Director, Farida E. Boyer
Chief Medical Officer, Dr. Taliba Foster
Clinical Coordinator, Kevana Nixon
Mental Health Therapist
Event Logistics
Date of event
-
Month
-
Day
Year
Date
Time of Event
Hour Minutes
AM
PM
AM/PM Option
Type of Event
Please Select
Virtual
In-person
Hybrid
Time of Arrival
Hour Minutes
AM
PM
AM/PM Option
Length of time BBC is expected to speak (ex: 20 minutes Resources)
Location (if applicable)
Address (if applicable)
Please select the type of event
Interview
Honoree
Keynote Speaker
Panelist
Moderator
Guest Speaker (TV, Radio, Podcast)
Guest Speaker (Company, Community event, etc.)
Roundtable
Undetermined
Other
Please Choose any of the following to help us with the theme for your event.
Personal Narrative
BBC History
BBC Services (Mental Health)
BBC LEAP ( Licensure Assistance)
Mental Health Training
Education & Training for Clinicians
Community Outreach
Mental Health Resources
Other
Do you need any of this deliverables from us?
Head Shot
Bio (please note length limitations below)
Additional photos (please specify below)
Video (please specify)
Other
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?
Yes
No
Will share at a later time.
Attachments
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a budget?
Yes
No
Budget Amount
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?
Extremely difficult
Somewhat difficult
Neither easy nor difficult
Extremely Easy
Submit
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