Name *

First Name

Last Name

Phone *

(###)

###

####

Event Date(s) *

MM

DD

YYYY

Event Start Time *

Hour

Minute

Second

AM PM

Arrival Date *

MM

DD

YYYY

Arrival Time *

Hour

Minute

Second

AM PM

Transportation & Accomodations

Please select which accommodations you are able to provide – separate from the honorarium.

5 Hotel Rooms (2 beds in each room)

All Meals

Flights (if your event location is over 8 hours driving distance from Southeastern University in Lakeland, FL)

Ground Transportation