Morehouse School of Medicine Speaker and Appearance Request Form

This form is designed to capture speaking and media engagement, as well as appearance requests, for a Morehouse School of Medicine expert.

Disclaimer

Please keep in mind that due to the volume of requests, schedules are extremely limited with regard to the ability to attend/speak at events that are not Morehouse School of Medicine mission driven. Priority will be given to organizations that provide service or support to the mission of Morehouse School of Medicine. Speaking/appearance fees, honorariums, or donations may apply and are determined based on the size, location, and type of event.

Today's Date*

Date of the Event:

Please select the person being requested:

Select or enter value

Since you selected other, please provide the name and title of the person you are requesting:

Describe the nature of the request*

Select

If other, please provide more detail:

Name of Organization/Company:

Please describe the mission of your organization.

Will this engagement be in person or virtual?*

Select

Location of Event (City, State and Venue):

If the event is virtual/online, then please provide the platform that will be used i.e. Microsoft Teams, Zoom, Facebook, etc.

Please give a brief overview of the event (e.g., conference, webinar, employee meeting, fundraising dinner, luncheon...)*

Please provide as much detail as possible.

If applicable, please list the names, title, and affiliation of the other speakers/panelists. If not confirmed at this time, then please describe the potential candidates being considered.

Time: (please note arrival and departure times for the speaker)*

Speech topic requested:*

Length of speech: (please note any time requested for Q/A)*

Please describe the audience who will be attending:*

Please provide sample of immediate past or noteworthy speakers of this event:

Media:*

Please detail any media attending or expectations, including social media engagement. If expected to conduct interviews in conjunction with the request, Morehouse School of Medicine's Marketing and Communications team must be included in all planning.

Please list any special meetings or dinners the speaker is expected to attend. Please include the groups or attendees names.*

Put n/a if not applicable.

Where applicable, it is expected that all lodging, airline, and ground transportation expenses are covered by the requesting organization.*

Please specify any restrictions or policies to which the invited speaker must adhere:

Will an honorarium be provided?*

Yes

If yes to honorarium, how much?

In lieu of flowers, plaques, awards, and certificates, Dr. Valerie Montgomery Rice kindly requests a donation to the Morehouse School of Medicine Presidential Scholarship Fund. The scholarship fund supports the education of bright, promising future health care professionals. Please visit https://giving.msm.edu for more information about Morehouse School of Medicine and the Presidential Scholarship Fund.

File Upload

Feel free to upload official letter of invitation, program/brochure samples or drafts, or any files in support of your request.

Drag and drop files here or

Contact Information:

Please provide the following information for the best person to contact regarding this request:

Name and Title:*

Email Address:*

Phone:

Send me a copy of my responses

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