Part I:  Media Release

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  • As 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
  • MEDIA COVERAGE The 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. I have read the above information and Agree to allow media coverage of my comments and appearance at this event. Decline to allow media coverage of my comments and appearance at this event. Signed, _______________________________________________________________ Printed Name: Date:
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    1. Name (as it should appear in all publications):
    2. Title (as it should appear in all publications):
    3. Company Name (as it should appear in all publications):
    4. Mailing Address:
    5. E-Mail Address:
    6. Speaker's Assistant’s name:
    7. Assistant’s E-Mail:
    8. Assistant’s Phone Number:
    9. Speaker's on-campus contact:
    10. Title of the speech?
    11. Nature and content of speech:
    12. Preferred format of speech?
    13. Does the speaker want to mail any materials to be distributed during or after the speech? If yes, please describe:
    14. Does the speaker have a book or other prominent piece of press material that is important to them or that is relative to their speech at hand?___If so, would the speaker be willing to sign copies?____
    15. Please describe all audiovisual (AV) needs (microphone, PC, etc.):
    16. Are translation/ interpretation services needed?
    17. Does the speaker have any disability (e.g., in a wheelchair, etc.) of which we should be aware so that we can make appropriate arrangements?
    18. Does the speaker have any particular dietary requirements?
    19. Beverage preference during the event?
    20. Are there any other special needs, requirements or requests of which we should be aware in planning for the speaker?
    21. Does the speaker require any specific security arrangements?
    22. Will the speaker be travelling alone or will she/he be accompanied?
    If the speaker will be accompanied, what are the names and titles of those people? Do they have any special needs? Please provide:
    • Print photo
    • Electronic photo (.jpg or .gif)
    • Biography
    • Company website
  • By typing your name or initials in the signature box, you have signed consent for this release.

Part II: Speaker Questionnaire

  1. Name (as it should appear in all publications):
  2. Title (as it should appear in all publications):
  3. Company Name (as it should appear in all publications):
  4. Mailing Address:
  5. E-Mail Address:
  6. Speaker’s Assistant’s name:
  7. Assistant’s E-Mail:
  8. Assistant’s Phone Number:
  9. Speaker’s on-campus contact:
  10. Title of the speech?
  11. Nature and content of speech:
  12. Preferred format of speech?
  13. Does the speaker want to mail any materials to be distributed during or after the speech? If yes, please describe:
  14. Does the speaker have a book or other prominent piece of press material that is important to them or that is relative to their speech at hand?___If so, would the speaker be willing to sign copies?____
  15. Please describe all audiovisual (AV) needs (microphone, PC, etc.):
  16. Are translation/ interpretation services needed?
  17. Does the speaker have any disability (e.g., in a wheelchair, etc.) of which we should be aware so that we can make appropriate arrangements?
  18. Does the speaker have any particular dietary requirements?
  19. Beverage preference during the event?
  20. Are there any other special needs, requirements or requests of which we should be aware in planning for the speaker?
  21. Does the speaker require any specific security arrangements?
  22. Will the speaker be travelling alone or will she/he be accompanied?

If the speaker will be accompanied, what are the names and titles of those people?

Do they have any special needs?

Please provide:

  • Print photo
  • Electronic photo (.jpg or .gif)
  • Biography
  • Company website