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Seminar Request Form

Due to the large number of requests we receive for on-site speaking and seminar engagements, the Center for Parent/Youth Understanding has established a screening process to help us discern and manage our seminar/speaking schedule. While we would like to be able to fulfill all speaking/seminar requests, we are unable to do so. In order to allow our staff an opportunity to give prayerful and serious consideration to your request, we are asking you to complete the Seminar Request Form in its entirety. After receiving your completed form, we will contact you regarding seminar/speaker availability for your requested dates. Thanks for your interest in CPYU!

Sponsoring Organization Information
Church/Organization Name:*
Contact Name:*
First Last
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Alternate Phone:
Email*
Event Information
Check the name(s) of the speaker you are requesting.
- Walt Mueller
- Jason Soucinek
- Paul Robertson
- Marv Penner
- Amy Flavin
- Duffy Robbins
What is the title of the seminar you are requesting?
Do you intend to hold the event at the address provided above?*
- Yes
- No
Location of Event (If different from address provided above):
Street Address City State / Province / Region ZIP / Postal Code Country
Preferred Date #1:*
Preferred Date #2:
Preferred Date #3:
Check the intended seminar length you are hoping for:*
- Half Day (2-3 hours)
- Full Day (up to 6 hours)
- Multi-Day Event
Number of attendees expected:
Amount budgeted for Honorarium:*
Amount budgeted for Travel/Accommodation Expenses:*
What are your hopes for this event?
How does this event fit into your overall ministry strategy and objectives?
Are there specific topics you'd like addressed in the seminar?
Describe your target audience. Who is likely to attend? Is it youth workers, parents, educators, teens, pastors, etc.?
What type of publicity will you use?
Will the event be a cooperative effort with other churches/schools/etc.?
How did you hear about CPYU?
Phone
This field is for validation purposes and should be left unchanged.

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January 22 @ 3:30 pm - January 23 @ 4:00 pm

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Center for Parent/Youth Understanding
PO Box 414
Elizabethtown, PA 17022
(717) 361-8429
Fax: (717) 361-8964

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