Media Request Form – Land of Promise

First Name *

Last Name *

Event Title/Theme *

Event Date *

Event Time *

Event Location *

Describe the Event *

(Provide a brief write-up of the purpose, etc.)

Guest Presenter's Name/Profile (Name, Brief bio, etc.) *

(Provide a brief write-up of the purpose, etc.)

Name of Primary Event Coordinator *

Primary Event Coordinator's Phone Number *

Primary Event Coordinator's Email Address *

Name of Secondary Event Coordinator *

Secondary Event Coordinator's Phone Number *

Secondary Event Coordinator's Email *

What digital format are you submitting? *

If other, please list digital format below.

What media support are you requesting? *

If other, what type of media support are you seeking?

If other, please list below.

Email