Education & Awareness Presentation Registration Form

Education & Awareness Presentation Registration Form
Contact Name*

First NameLast Name
Name of Organization*
Contact Phone Number*

Area CodePhone Number
Contact E-mail*
Date and Time of Presentation*
Is this presentation:*

VirtualIn-PersonHybrid (Organization is responsible for technology)
Location of Presentation (if in person):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Desired Length of Presentation: *
Estimated Number of Attendees: *
Who would this presentation be for: *
(Ex: Parents, students in grades 11/12, mental health professionals, etc.)
Context of the event: *
(Ex: Wellness Day, PTO meeting, Health class, etc.)
Technology provided for the presentation (Please check all that apply):

LaptopProjector/ScreenMicrophone
Please indicate any other information you would like us to know about this training:
There is a minimum donation of $275/hr presentation. Will you be making this donation? Or another amount?*

Yes
Amount:
Minimum $275, all amounts are appreciated
By signing this document, I acknowledge that the Multi-Service Eating Disorders Association (MEDA) is offering to present for the benefit of the community. I acknowledge that it is my responsibility to market this event as well as organize and manage the setting, audience, and any other administrative needs of the event. If these guidelines are not adhered to, I understand that MEDA reserves the right to stop or cancel the presentation.
First NameLast Name
MonthDayYear
Questions or concerns? Contact: education@medainc.org
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