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.
Format: (000) 000-0000.
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.
Elder Exploitation and Abuse: Types of abuse, warning signs, risk factors and protective factors, trauma informed responses to survivors of abuse and exploitation.
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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