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.

Event Information
8. * What Speakers' Bureau topic would you like us to present at your event?	Asthma Bed Bugs Cardiovascular Disease Cholesterol Diabetes Emergency Preparedness Falls Prevention Hantavirus High Blood Pressure Pertussis PH 101 Preconception Health Seasonal Flu West Nile Virus
9. What kind of event would you like us to attend? Note: These presentations use a lecture format and would not be appropriate for a health or community resource fair.	Conference Community Meeting Professional Meeting Other:
10. What date are you proposing?
Note: We need to know about the event at least 3-4 weeks in advance in order to try to accommodate this request.
11. What times are you proposing?
12. How much time would we have to present?
Note: We need to present for at least 30 minutes to try to accomodate this request
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?	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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