Request for a Health-related Presentation
Full Name
*
First Name
Last Name
Email
*
Please re-enter your email
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization
*
Presentation Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presentation Time
*
Hour Minutes
AM
PM
AM/PM Option
Alternate Presentation Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Alternate Presentation Time
*
Hour Minutes
AM
PM
AM/PM Option
Desired length ofpresentation, including post presentation questions
*
Location of Presentation
*
Equipment to be provided
*
Computer
Projector
Screen
Digital pointer/slide advance remote
Other
Approximate Number of People expected to attend
*
Expected Audience
*
i.e. Rotary Club Members, Park staff
Please describe, with as much detail as possible, the health topic for which you are requesting a presentation
*
Submit
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