Wufoo

Speakers Bureau Presentation Request

To request a Spectrum Speakers Bureau Presentation for your class or organization, please fill out this form at least 3 weeks in advance.

Name * First Last
Phone ### - ### - ####
Other Phone ### - ### - ####
Email
Location of Presentation
Date of Presentation (first choice) MM / DD / YYYY
Time of Presentation HH : MM : SS AM/PM
Date of Presentation (second choice) MM / DD / YYYY
Time of Presentation HH : MM : SS AM/PM
Desired Length of Presentation
Type of Presentation
Classroom Agency/Staff Meeting Clinical Training Other
Classroom Presentation: please list the class name and grade level
Number of Speakers Requested
1 2 3
Audience Size
Short description of audience knowledge level in lgbt issues
Additional info you would like us to know
Do Not Fill This Out