Pre – Program Questionnaire

This questionnaire is designed to help Ms. Starr prepare a program that is specifically tailored to the needs of your group. Please take a moment to answer the questions and email Ms. Starr at ggloria(Replace this parenthesis with the @ sign)gloriastarr.com . If you wish to send additional information please include it at the end of this form.

Your Name: (required)

Cell Phone: (required)

Email: (required)

Audience Information

Number of Attendees:

Major responsibilities of audience members, and typical job titles:

The Program Itself

Conference Theme:

What is your specific objective for this session?:

Information about the person who will be introducing me.

Name:

Phone:

Email:

Starting time for my program:

Starting time of entire event:

Ending time for my program:

Ending time of entire event:

What takes place before my program (speaker, meal, workshop):

What takes place immediately after my program (break, another speaker, lunch):

Name of: City, Hotel, Confirmation Number, Meeting Room:

City:

Hotel:

Confirmation Number:

Meeting Room:

What areas do you feel need the most improvement? :

At the completion of this presentation what do you want to be uppermost in their minds? :

Any other comments you would like to add?

In case of emergency I should call:

Name:

Day and evening phone:

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