Speaker Intake Form

Speaker Information

Name(Required)

Prefix First Last Suffix

Preferred Pronouns(Required)

Job Title(Required)

Company/Organization(Required)

Email(Required)

Phone(Required)

Additional Contacts

Do you have a day-of contact with whom we should coordinate?(Required)

Yes

Day-of Contact Name

First Last

Day-of Contact Email

Day-of Contact Phone

Do you have a PR or media contact with whom we should coordinate?(Required)

Yes

PR/Media Contact

First Last

PR/Media Email

PR/Media Phone

Promotional Information

Presentation or Workshop Title(Required)

Presentation or Workshop Description(Required)

Speaker Headshot(Required)

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

Speaker Bio(Required)

Max. file size: 100 MB.

Can we tag you in our social media marketing?(Required)

Yes

Twitter Handle

LinkedIn Profile

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 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 with my performance or appearance.

I have read the above release and(Required)

Agree

Decline

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.

I have read the above information and(Required)

Agree to allow INTERNAL Wharton media coverage of my comments and appearance at this event.

Agree to allow EXTERNAL INDEPENDENT media coverage of my comments and appearance at this event.

Decline to allow media coverage of my comments and appearance at this event.

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