Amplify: A consumer voices bureau

Amplify: A consumer voices bureau request form
Title of event/project *
Event/project type *
Description of event/project *
If you would like to request a specific person/people for your event/project, list their name(s) here
Start date

Month Day Year
End date (if multiple day event/project)

Month Day Year
Are dates flexible? *

Yes No Unsure
Will event/project be held in-person or virtually? *

In-person Virtually Both Unsure
Location of event (if in-person)
Event venue (if in-person)
Is the event venue ADA accessible?

Yes No Unsure
Host Organization(s) *
How did you hear about Amplify? *

A friend/colleague National Center/Coalition email Another email promotion National Center/Coalition website Social media (Facebook, LinkedIn, etc.) Through a Speakers Bureau participant Through a work event (webinar, conference, etc.)
Please download and read our values statement for authentic and empowering consumer engagement, and indicate below that you have read and understood the statements.
*

Yes, I have read and understood the statements Yes, but I have some questions, or would like to discuss these further
How will participant(s) be compensated for their work on this event/project? *
Contact Information
First Name *
Last Name *
Job Title
Organization *
E-mail *
Phone Number *

Area Code Phone Number
Updates from the National Center

I would like to receive update emails from the National Center
Date of Outreach

Month Day Year
Date
Should be Empty:

Amplify: A consumer voices bureau request form