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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!


Attention DPH Staff: Do not use this form to report participation in an outreach event that's not related to Speakers' Bureau. Instead, please use the DPH Staff Participation in Outreach Event form located online at http://www.surveymonkey.com/s/dph-outreach. Only report outreach events that you've participated in the past (do not include future outreach events). Thank you!


Requester Information

1. Today's Date: 10/22/2014
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?         
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:
 
*Code:   What's this? | Refresh for a new code(Refresh)
 
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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