Contact

Who would you like to work with?*
Dr. Charles R. RogersDr. Tiana N. RogersDr. Charles & Tiana Rogers

Name of Company/Organization Submitting Request*

Point of Contact Name*

Point of Contact Email*

Point of Contact Phone

Company, Organization, or Event Website*

Event/Collaboration Date*

Event Name/Title (if applicable)

Event Location (if applicable)

Event Time & Time Zone (if applicable)

Request Type*
CollaborationConferenceDinnerInterviewTrainingSmall GroupOther

What role(s) would you like fulfilled?*
Guest LecturerFacilitator (Breakout Session)Facilitator (Group Session)Keynote SpeakerMedia Interviewee (Radio, Television, etc.)PanelistResearch-focused CollaboratorOther
Please select ALL that apply.

Estimated Duration of Event/Collaboration*

Requested Topic(s) or Collaboration Need*

Estimated Number of Attendees (if applicable)

Nearest Airport (if applicable)

Offer of Payment/Reimbursement*

How you heard about us*
BLKhaven.comCRCequity.orgcrrogersPhD.comFacebookInstagramLinkedInXReferralOther
Please select ALL that apply.

Deadline for Acceptance*

Consultation Type (if applicable)
30-min Consult - $250