MADRC Speaker Request Form

Thank you for reaching out to the Massachusetts Alzheimer’s Disease Research Center (MADRC). We have an extensive Speakers’ Bureau made up of faculty willing to give educational talks in Boston and surrounding communities about memory, aging and Alzheimer’s Disease.

Generally, we require a minimum of 15 attendees for your program and ask that you promote it widely.

PLEASE NOTE: It may take up to 2 weeks to receive a response and up to 3 months to book a program. Your request will be reviewed by our committee and a decision will be made based on other outreach events taking place at that time.

There is no fee for this service: however, donations to our organization can be made online here: http://bwhgiving.org/cart

Questions: Please call 617-278-0383

Select the type of program you are hosting from the list below:

Community Education

Health Fair Table Memory Research Update Panel Presentation (specify topic below) Workplace presentation (specify topic below)

Road Map Series Session: one hour educational programs for people concerned about aging and memory loss (choose one)

Road Map to Dementia Diagnosis Road Map to Research Participation Road Map to Caregiving Road Map to Prevention

Healthcare Professionals Education Program

Grand Rounds Memory Research Update Road Map to Dementia Diagnosis Presenter for Conference

Requester Contact Information

Today's Date

Name

Email Address

Telephone Number

Your Organization & Address

Address of presentation location: street, city/town, zip code

Program contact name and email:

List three potential dates for this program

Time of Program

Program Details (length of presentation, A/V needs, number of attendees)

Please provide any additional information that would be helpful for us to honor your request:

MADRC contact (if applicable)

We appreciate your interest in the MADRC Speakers’ Bureau.