CHCS Speaker Bureau Request Form

CHCS Speaker's Bureau Request Form

Interested in having a CHCS representative speak at your event? Please complete this form with specific information about the event and speaker requirements. Note: Please submit your request minimally 3-4 weeks in advance to ensure speaker availability.
Agency Contact Information
Sponsoring Organization:
Contact Name:

First NameLast Name
Phone Number

Area CodePhone Number
Contact Email:
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Event Address (if location is same as above, please state "same as above"):
Onsite Contact on the Day of Event:

First NameLast Name
Onsite Contact on the Day of Event:

Area CodePhone Number
Information About Your Request
Requested Date of Presentation (1st Choice)

MonthDayYear
Requested Date of Presentation (2nd Choice)

MonthDayYear
Requested Date of Presentation (3rd Choice)

MonthDayYear
Time of Presentation

:HourMinutesAM/PM Option
Length of Presentation (in minutes):
Approximate Size of Audience Expected:
Type of Audience (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
Proposed Topic(s):
Preferred Presenter, please rank your preference below by moving the type of presenter to 1st-3rd position.
Presentation Format:

Panel DiscussionSpeech/PresentationAuditorium Style LectureRoundtable DiscussionOther
Will Audio/Visual be needed and provided?

YesNoOther
Contact Person for AV Arrangements:

First NameLast Name
Please provide any necessary information on directions, how early the speaker should arrive before the presentation, where and to whom to report upon arrival, etc.
Additional Comments to help us in selecting your presenter:
The Center for Health Care Services wants to provide you with the best quality presenter for your speaking engagement event. Please keep in mind that all our speakers are volunteering their time. Therefore, we may not be able to fulfill every request that is received. We will keep you posted 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 basis, 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.

Our speaker may also bring materials regarding services provided by The Center for Health Care Services. If your agency does not allow us to provide materials, please let us know.
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CHCS Speaker's Bureau Request Form