Booking Booking Name of Organization?Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Your Full Name First Last Best Contact NumberEmail Date & Time requested for service OtherLength of service90 minutes60 minutes30 minutes20 minutes15 minutes10 minutesTo be determinedOtherSelect Service Requested Consulting Performance Powerpoint Presentation Guest Appearance Keynote Address or Closing Plenary Presentation Commencement Speaker Motivational/Inspirational Speaker Customized Topic Tailored to Our Event Comedy Select Performance Requested Mama Juggs Show: Breast Health/Cancer Awareness/Prevention, Self-Esteem, and Body Image Don’t Wait Until It’s Too Late Show: Real Breast Cancer Experience with Documentary The Men In Me Show: Urban Male Issues HIV/AIDS, Domestic Violence, Recidivism, Sex Trafficking, Marriage & Police Brutality Bucking the Bull: Black Male Experiences with the Medical & Health Care System in America Boomerang Show: Sharpening Awareness about Racism & Sexism in the Workplace First Food Desert: Breastfeeding Education Trials, Not Tribulations Show: Encouraging Clinical Trial Participation by African-Americans & Choosing the Clinical Trial that Best Fits You Wake Up to Stay Alive: Understanding Health Disparities in Black Males Fooling Yourself Into Fun Foods & Fitness Show: Simple Ways To Live A Healthier Life Health & Nutrition Show: Great-Grandma’s Healthy Kitchen Educational Demo Remodeling the Brick House Show: A Successful Journey to Reverse Pre-Diabetes & Obesity Other: Commissioned Original Work Select Workshop/Residency Requested Educational Health Presentation HIV/AIDS Prevention Workshop Forgiveness & Self-Empowerment Workshop Flipping the Script on Self-Esteem: Creating Your Own Powerful Future with Practical Life & Social Skills through Improv Workshop Standup Sketch Comedy on a specific topic Personal Narrative & Literary Skills Development Residency Inner-Work & Self-Compassion Workshop How to Lose Weight & Gain Your Life Back after a Health Scare African & African-American Geniuses in Current Living & Past History African Face Painting with Adinkra Symbols Other Amount budgeted for the requested service?Name of venue location?Full Address of the venue/location?Is this a conference? If yes, what are the official start & end dates?Anticipated/Estimated Attendance?Type of GroupHospitalCollege or UniversityProfessionalsK-5th grades6-8th grades9-12th gradesFaith-BasedMethod of Payment?Cashier’s check, Company check, or money order guaranteed form of paymentCredit Card (We accept all major credit cards. *add 3.00% service charge to fee)Electronic Funds Transfer (Add $15 service fee per EFT transmission)Does your organization provide roundtrip transportation and lodging?YesNoIf not, an all-inclusive quote will be preparedPerson who approves and authorizes contract agreements?Name First Last Email PhoneContact person for payment?Name First Last Email PhoneDescription of the event & additional information: (Please note: This amount does not include Transportation, Lodging, Meals or Incidentals):CAPTCHA