WCA Speaker Intake Form Name*Please enter your name as it should appear on all materials such as marketing emails, printed programs, etc. First Last Job Title*Please enter your job title exactly how you would like WCA to use it on event materials. Company / Organization*Please enter the name of your organization exactly how you would like WCA to use it in event materials. Email* Cell Phone*Preferred Pronouns*-she/her/hershe/him/histhey/them/theirsze/hir/hirsxe/xem/xyrsze/zir/zirsprefer not to answernot listedPlease provide your preferred pronoun:Logistical InformationName of day-of contact, if not yourself First Last Email PhonePresentation / Workshop InformationHeadshot*Please provide a high-res headshot. This will be displayed on our website and in our event program. Accepted file types: jpg, png.Bio*Please provide a brief bio about yourself. Presentation or workshop title*Please enter the title of your presentation or workshop exactly how you would like WCA to use it on event materials. Presentation or workshop summary.*For marketing purposes, please provide a few sentences about your presentation. Media ParticipationDo you have a Media or PR department that we should coordinate with?YesNoPR / Media Contact First Last Media / PR Email Are you active on social media?YesNoWill you help promote the conference through your social media channels?Feel free to post about the conference on you own, WCA will also tag you in any posts related to your involvement.YesNoSocial Media Handle(s)Please provide any social media handles, if applicable. If more than one, please separate them with a comma. Live Streaming?Would you be interested in having your presentation streamed live through Facebook or Twitter? YesNoPotentially, but I need to check with my PR department fist.Media Outlets?Would you be willing to be interviewed by one of Wharton's media outlets?YesNoMedia ReleaseAs part of my appearance at the Wharton School, I give permission to record me, including images, audio, presentation and comments, with my name included, for use in in electronic and print publications; and the School’s educational and engagement programs for potential and enrolled students, alumni and Friends of Wharton and Penn; The Wharton School may use these reproductions without further examination by me. I waive all personal claims, causes of action, liabilities, or damages against the School arising from or in connection.I have read the above release and: Agree to allow recording for Educational use Agree to allow recording for Promotional use Decline to allow recording for Educational use Decline to allow recording for Promotional use Media CoverageThe Wharton School tends to allow media coverage of all public events. Media outlets include, but are not limited to internal independent media such as Knowledge@Wharton, Wharton Magazine, Wharton Journal, Daily Pennsylvanian and external independent media both local Philadelphia and beyond. The Wharton Media Relations Office is the direct liaison with the speaker/speaker’s office to ensure the maximum level of comfort with any public coverage of the event. If you would like to connect with our Media Relations office, please inform the organizers so they may make the introduction.Media Coverage Consent*I have read the above information and AGREE to allow media coverage of my comments and appearance at this event.I have read the above information and DECLINE to allow media coverage of my comments and appearance at this event.