President/CEO Speaker Request Form

President/CEO Speaker Request Form

Jeylnne LeBlanc Jamison, CHCS President/CEO believes in giving back to our local community. If you are interested in having her speak at your event, please complete the form below with specific information about the event and speaker requirements. Note: Please submit your request minimally 4-6 weeks in advance to ensure speaker availability.
Event Contact Details
Inviting Organization:*
Contact Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Contact Email:*
Onsite Contact on the Day of Event:*

First NameLast Name
Onsite Contact Phone on the Day of Event:*

Area CodePhone Number
Event Details
Event Name*
Event Type*
Address Type*
Formally recorded or published?*
Event Description*
Event Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Event Start*

MonthDayYear
Event End*

MonthDayYear
Speaking Start Time*

:HourMinutesAM/PM Option
Speaking Duration*
Expected Audience Size:*
Audience Type (check all that apply)*

Business Group (ex: Rotary Club or Chamber of Commerce)Professional or Service Organization (ex: Kiwanis Club or Junior League)Workplace Group (ex: Employees)Training for Workplace GroupReligious OrganizationPolitical Organization (ex: Democratic or Republican Party or League of Women Voters)School/Educational InstitutionGeneral CommunityFamiliesOther
Deadline to receive speaker confirmation*

MonthDayYear
Date
Would you be willing to accept a surrogate speaker if Mrs. Jamison is unable to participate?*
Additional Comments
The Center for Health Care Services wants to provide you with the best presentation for your speaking engagement event. Please keep in mind that Mrs. Jamison is volunteering her time therefore, we may not be able to fulfill every request. We will keep you updated on the progress of your speaking engagement request either via email or phone. If you feel you are not hearing from us in a timely manner, please feel free to contact our office at 210-261-1012.

For quality assurance, we may follow up with you after the event for feedback to continually improve our services.
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