Booking Request Form s1

Booking Request Form

DATE OF EVENT: / Date of Request:
Organisation Name: / Contact name:
Contact email address:
Contact Telephone Numbers:
Organisation Address:
Name of Event: / Time of Event Start:
Event address: / Time of Presenting:
Time of Event Finish:
Duration for Presentation:
45 mins or 1 hour?
Audience size / Number:
Audience Type: / Children/ Teachers/ Parents/ Support Professionals/ Governors/ Police/ Health
If children please circle Year group / Reception / 1-2 / 3-4 / 5-6 / 7-8 / 9-10 / >11
Purpose of Event:
Is it an Open Event?
(An event to be publicised)
Where to Publicise?
Specific Topics to cover:
Any other requirements e.g. Special Needs etc.
Fee Structure: (plus travel expenses. Mileage at 45p a mile from Kent) – Please tick appropriate box
The Breck Foundation is a self-funding charity and all fees are used to continue our important work of empowering and educating people to be safer whilst online.
School
(Day Session) / School
(1 Hour Evening Session) / Conference
(Half day / Full day)
1-hour / 2-hour Session / Media Requests
Founder (Lorin LaFave) –
In the event of your booked speaker not being available, we will do all we can to find a suitable replacement.
£750 (first hour)
£100 per session thereafter
£150 per evening session thereafter / £750 / £750/£1500 / to be determined
Foundation Speaker –
In the event of your booked speaker not being available, we will do all we can to find a suitable replacement.
£250 (first hour)
£100 per session thereafter
£150 per evening session thereafter / £350 / £500/£1000 / to be determined
Nearest Rail Station: / Is overnight
accommodation required for the speaker due to
location or start time of the first/ final presentation?
Is Parking available on site? / Accommodation for speaker Booked/Where:
Would you like us to bring Breck Foundation Merchandise to purchase at the end of your session?
Pen/ Pencil
£1 / Wristband
£1 / Cloth Shopping Bag
£4 / Murder Games DVD
£20

The Breck Foundation

Sunnydown School, 152 Whyteleafe Road,

Caterham, Surrey, CR3 5ED

Registered Charity Number: 1168384

PLAY VIRTUAL / LIVE REAL