Speaker Request Form
Use this form to request a presentation from Senior Resources Eastern Connecticut Area Agency on Aging.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Who is the presentation audience?
How would you like the presentation facilitated?
In-person
Virtual
Hybrid
If in-person, what is the name of the organization/location you would like us to present at?
What is the address of the organization/location you would like us to present at?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What date would you like the presentation?
-
Month
-
Day
Year
Date
What time would you like the presentation?
Hour Minutes
AM
PM
AM/PM Option
What topic(s) would you like presented? (These are 1-session presentations unless otherwise noted)
Aging Answers: Overview of programs, services, and grants.
Medicare Bootcamp: Basics, enrollment, coverage, cost savings, and preventative services.
Senior Medicare Patrol: How to prevent and detect Medicare fraud.
Healthy Eating for Healthy Aging: Nutrition and wellness tips from a registered dietitian.
Dementia Friends: Understanding dementia and supporting those affected.
Mind Over Matter: A 3-session program for women age 50 or over to manage issues related to bowel and bladder incontinence.
Powerful Tools for Caregivers: A 6-week program to help caregivers manage stress, improve communication, and practice self-care.
Live Well: 6 weekly classes on managing chronic conditions, diabetes, and pain through healthy habits and self-care.
Special Topic catered to your audience
If you selected special topic or have any additional information we should know about your request, please elaborate here.
Submit
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