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 two 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 5 business days of submitting this request.

If you are experiencing technical issues using this form, please contact HEA at (213) 351-7854 or via email at speakersbureau@ph.lacounty.gov. Thank you.

Event Information
8. * What topic would you like us to present at your event?	Asthma Bed Bugs Cardiovascular Disease Cholesterol Diabetes Emergency Preparedness Falls Prevention High Blood Pressure Pertussis PH 101 Preconception Health Seasonal Flu Tuberculosis
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?	1 hour 1.5 hours 2 hours
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)