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

MonthDayYear
End date (if multiple day event/project)

MonthDayYear
Are dates flexible?*

YesNoUnsure
Will event/project be held in-person or virtually?*

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

YesNoUnsure
Host Organization(s)*
How did you hear about Amplify?*

A friend/colleagueNational Center/Coalition emailAnother email promotionNational Center/Coalition websiteSocial media (Facebook, LinkedIn, etc.)Through a Speakers Bureau participantThrough a work event (webinar, conference, etc.)Other
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 statementsYes, 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 CodePhone Number
Updates from the Camden Coalition

I would like to receive update emails from the Camden Coalition
Date of Outreach

MonthDayYear
Date
Should be Empty:

Amplify: A consumer voices bureau request form