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Speakers' Bureau Community Request Form     (*Required Fields)

Complete this form to request a Speakers' Bureau presentation. Please note presentations are fulfilled on a first-come, first-served basis. Submitting a request does not guarantee a presenter can attend your event. However, submitting three weeks or more in advance will improve our ability to accommodate your needs. You will receive an e-mail or phone call accepting or declining your invitation within 7-10 business days of submitting this request. You will also receive a confirmation number for request tracking purposes.

IMPORTANT: All Speakers’ Bureau presentations have been prepared for general community audiences unless otherwise noted on the Speakers’ Bureau webpage. If you require a presentation that’s intended for health professionals and other clinical audiences, please make a note of this in the comments section of the request form and provide specific information about the audience type you’d like us to serve through the presentation. Once again, submitting a request does not guarantee a presenter can attend your event.

If you are experiencing technical issues using this form, please download the PDF version of the request form and submit it by email to speakersbureau@ph.lacounty.gov. Thank you!


Requester Information

1. Today's Date: 04/19/2014
2. * First Name:
3. * Last Name:
4. * Organization or Department:
5. * Phone Number: 555-555-5555
6. * E-mail:
7. * How did you hear about us? Department of Public Health Website
Health Education Administration Website
Other:

Event Information

8. * What topic would you like us to present at your event?          Other Topic:
9. What kind of event would you like us to attend?

Note: Please indicate if this is a request for a lecture or a health fair.
Conference
Community Meeting
Health Fair
Professional Meeting
Other:
10. What date are you proposing?    (Event date no sooner than 3 weeks or 3 months after today)
Note: We need to know about the event at least 3 or 4 weeks in advance to try to accommodate this request. Due to an increased demand for outreach events during flu season (October-March), may ask to reschedule your event.
11. What times are you proposing? (start time between 8:00A.M - 6:00P.M Only)
12. How much time would we have to present?
13. How many people do you expect will attend your event?
Note: Please provide a group of at least 20 attendees for the event.
14. Who will attend your event?
Note: Remember to check all that apply.
Business Representatives
Community-Based Organization Representatives
College-Age Students
Elementary School-Age Students
Faith-Based Group
Government Agency Representatives
Health Professionals
High School-Age Students
Los Angeles County Employees
Parents
Seniors
Other:

15. What is the address of where your event will take place?
* Street Address:
* City:
* Zip Code:

16. Do you need the presentation to be in a language other than English?
Spanish
Other:
Note: Some materials are only available in English at this time.  
 
Comments:
 
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Remember, you will receive an e-mail or phone call accepting or declining your invitation within 5 business days of submitting this request.
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