Australian of the Year Appearance Request Form

Organisation *

Organisation Contact Name: *

Date/s of proposed event *

Location/State of proposed event *

What kind of event is this for? *

Fundraiser / Charity
Corporate
Professional
Awareness
School Visit
Other (Please specify)

Other (please specify)

The purpose of the proposed event *

Motivational
Informative
Leadership
Staff Engagement
Health & Wellness
Other (please specify)

Other (please specify)

What will the Alumni’s role be at the event? *

Keynote Speaker (duration of speech ___________)
Panel Member
Q & A session
Fireside Chats (format between MC & Speaker)
Other (please specify)

Is virtual attendance (video message, Skype/Teams) possible? *

Yes
No

Other (please specify)

How big is the audience? *

less than 20
21 – 50
50 – 100
Over 200
Other (please specify)

Other (please specify)

Are you able to cover flights, accommodation, and travel expenses? (if required) *

Yes
No
Other (please specify)

Other (please specify)

How long would you like the Alumni to attend for? *

Up to a 1 hour
Up to 2 hours
Up to 4 hours
Other (please specify)

Other (please specify)

Are you able to pay a speaker's fee if requested? Are you open to donating to the speaker's preferred charity in lieu if requested?

Yes
No
Other (please specify)

Other (please specify)