Event Request Form

Event Name*
Date of Event
MM slash DD slash YYYY
Time of Day
Time in h:am/pm format eg: 10am
Date of the event is*
Venue
Location (City, State, Country)
Contact Information
Contact Name*
Contact Email*
Phone
Event Details
Event purpose/objective
(please include how your event aligns with gender equity/diversity in STEM)
Ambassador’s role
Event Type
Estimated audience size/number of attendees
Who is the audience?
Other VIP attendees (if known)
Who are the event sponsors?
What steps have you taken to ensure diversity of speakers, panel members, etc.? (if applicable)
Will media be present at the event/is any media planned?
- Yes
- No
Are you able to provide travel and/or accommodation?
- Yes
- No
Event Background/Speaking Notes
The aim of this section is to provide the Women in STEM Ambassador with useful background information that will help her understanding of and inform her contribution to the event.

Contact Information