AIAB Speaker Intake Form

Name*

Please enter your name as it should appear on all materials such as marketing emails, printed programs, etc.

First Last

Job Title*

Please enter your job title exactly how you would like WCA to use it on event materials.

Company / Organization*

Please enter the name of your organization exactly how you would like WCA to use it in event materials.

Email*

Cell Phone*

Preferred Pronouns*

Please provide your preferred pronoun:

Logistical Information

Name of day-of contact, if not yourself

First Last

Email

Phone

Presentation / Workshop Information

Headshot

Please provide a high-res headshot. This will be displayed on our website and in our event program.

Accepted file types: jpg, png, Max. file size: 100 MB.

Bio

Please provide a brief bio about yourself.

Max. file size: 100 MB.

Presentation or workshop title*

Please enter the title of your presentation or workshop exactly how you would like WCA to use it on event materials.

Presentation or workshop summary.*

For marketing purposes, please provide a few sentences about your presentation.

Media Participation

Do you have a Media or PR department that we should coordinate with?

Yes
No

PR / Media Contact

First Last

Media / PR Email

Are you active on social media?

Yes
No

Will you help promote the conference through your social media channels?

Feel free to post about the conference on you own, WCA will also tag you in any posts related to your involvement.

Yes
No

Social Media Handle(s)

Please provide any social media handles, if applicable. If more than one, please separate them with a comma.

Live Streaming?

Would you be interested in having your presentation streamed live through Facebook or Twitter?

Yes
No
Potentially, but I need to check with my PR department fist.

Media Outlets?

Would you be willing to be interviewed by one of Wharton's media outlets?

Yes
No

Media Release

As part of my appearance at the Wharton School, I give permission to record me, including images, audio, presentation and comments, with my name included, for use in in electronic and print publications; and the School’s educational and engagement programs for potential and enrolled students, alumni and Friends of Wharton and Penn; The Wharton School may use these reproductions without further examination by me. I waive all personal claims, causes of action, liabilities, or damages against the School arising from or in connection.

I have read the above release and:

Agree to allow recording for Educational use
Agree to allow recording for Promotional use
Decline to allow recording for Educational use
Decline to allow recording for Promotional use

Media Coverage

The Wharton School tends to allow media coverage of all public events. Media outlets include, but are not limited to internal independent media such as Knowledge@Wharton, Wharton Magazine, Wharton Journal, Daily Pennsylvanian and external independent media both local Philadelphia and beyond. The Wharton Media Relations Office is the direct liaison with the speaker/speaker’s office to ensure the maximum level of comfort with any public coverage of the event. If you would like to connect with our Media Relations office, please inform the organizers so they may make the introduction.

Media Coverage Consent*

I have read the above information and AGREE to allow media coverage of my comments and appearance at this event.
I have read the above information and DECLINE to allow media coverage of my comments and appearance at this event.

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