Intake Form

Please tell us a little bit about you and we'll get back to you within two business days.

Name

Organization/School/University

Title/Position

Location (City, State)

Email

Phone Number

Event or conference title

Specific date or time frame

Debby’s visit will be done in conjunction with a community-wide read of Waking Up White

YesNoMaybe/Not Sure

Audience Members/Participants (check all those that apply)

Board of DirectorsCivicCorporateEducationEmployeesFaculty & AdminFaith CommunityHealth CareLeadership/ManagementNot-for-Profit/GrassrootsParentsStudentsOther (Please describe)

I am interested in:

Keynote Address - Debby will craft an address specific to the theme of your eventCommunity Presentation and Dialog - Appropriate for wide-range of participants and customized for learning objectiveProfessional Development Workshop / Training - Appropriate for wide range of participants and customized for learning objectiveOne-on-One Leadership Consulting - Can be done by video, phone or in personOrganizational Consulting - Ongoing engagement. Minimum 25 hours per year