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 Name Last Name
Phone Number*

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

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

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Event Start*

MonthDay Year
Event End*

MonthDay Year
Speaking Start Time*

:Hour Minutes AM/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 CommunityFamilies
Deadline to receive speaker confirmation*

MonthDay Year
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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