Speaker or Health Fair Request Form

 

We ask that you allow us 30 days advance notice of speaking requests.   If your date is sooner than 30 days, we may not be able to find a volunteer to present.  We are not able to accommodate all seminar requests but we will do our best.

*1.
Question - Required - Today's Date:




*2.

(Maximum response 255 chars, approx. 5 rows of text)

*3.

(Maximum response 255 chars, approx. 5 rows of text)

4. Fill out with the Direct Contact's information

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What's this?

*5.
Question - Required - Event Date Choice 1:




*6.  


7.
Question - Not Required - Event Date Choice 2:




8.  


*9.  


*10.
Question - Required - Target Audience:







*11.
Question - Required - Presentation Type:



*12.
Question - Required - Program Topic - Please choose one
Please make 1 selection from the choices below.

*13.
Question - Required - What audiovisual equipment is available at the location?

14.

 

When you hit submit, you will receive confirmation of receipt of your request to the named contact's email.

You will be notified of confirmation receipt within 7 business days of receiving the request as to if we can accomodate your request.  Due to limited resources, we are not able to accommodate all seminar requests but we will do our best. Thank you for submitting your speaker request form. 

   Please leave this field empty