PREPARE OUR YOUTH, INC.

 kwame ronnie Vanderhorst

Speaker Request Form

Please print. Your request will be processed immediately. POY Inc., reserves the right to schedule with first confirmation of   hosts requesting the same date.

             Date of Event _______________________ Time of Event _____________

             Title of Event _________________________________________________

             Location ______________________________________________________

  (City, State, Country, Hotel or Conference Center, Venue)

             Name of Sponsoring Organization ________________________________

             Type of Organization ___________________________________________

             Contact Name & Title __________________________________________

             Phone & Email _________________________________________________

            Target Audience _______________________________________________

            How would you like for mr. vanderhorst to participate?

           ___  Keynote Speaker                                                     ___  Workshop/Seminar Presenter

           ___  Plenary Speaker                                                       ___  Media Interview

           ___  Panelist                                                                     ___  Talk show, News/Documentary

           ___  Facilitator/Trainer                                                     ___  Plenary Speaker

           ___  Preaching Service                                                     ___  Consultant

          Goals of the Event

1.    _________________________________________________

2.    _________________________________________________

3.    _________________________________________________________________

Prepare Our Youth, Inc.  6856 Eastern Avenue, NW, Suite 207, Washington, D.C. 20012   

(202) 291-5040   (202) 291-5042 fax

Email: kwame@poyinc.org

Print form, complete and fax

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