Community Speaking Request Form

COMMUNITY SPEAKING REQUEST
Fees:

In-Services and Community Outreach (Presentations specifically about A Safe Place’s Programs and Services): $0

Community Tabling: $0

Training for Professional Development (Educational Training for Professional Students, Staff, etc.): Price is based on service hours dedicated to training preparation, with trainings being a minimum of 2 hours long
How Can We Help You?*

Speaker for Group Presentation/LectureA Safe Place Expert for Training PanelIn-Service Presentation about A Safe Place’s ServicesOther (please specify)
Please list at least two points that A Safe Place Should Focus on for this Event*
Preferred Date of Activity*

MonthDayYear
Date
Preferred Time of Activity (Weekdays Before 5pm Preferred) *

:HourMinutesAM/PM Option
Preferred Length of Activity*

:HourMinutes
Contact Name*

PrefixFirst NameLast Name
Company/Organization*

COMPANY NAME

Street Address

CityState / Province

Postal / Zip CodeCountry
Contact Number

Area CodePhone Number
E-mail*
Type of Group (Examples: Clients, Students, Volunteers, Interns, Staff, etc.) *
Projected Size of Group Attending*
How Did You Learn About A Safe Place's Speaking Program?
Please Put Any Notes You Would Like Us To Know About Below
Please Click Submit to Send the Form to Our Program Manager
Should be Empty:

COMMUNITY SPEAKING REQUEST