Contact Name *

First Name

Last Name

Preferred Event Date (s)

If you do not know an exact date, please share an estimated time frame.

(###)

###

####

What type of engagement are you interested in? *

Select all that apply.

Workshop

Extended Meeting Facilitation

Retreat Facilitation

Keynote Speaker

Podcast or Radio Interview

Something else super interesting

Are any of the participants or audience members currently enrolled in our Justice at Work online course?

No

Yes - less than half

Yes - more than half

Not sure

Would you like Mia to attend virtually or in-person? *

Please note that travel and lodging is not included in our fees.

Yes

No

Not Sure Yet