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:
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):
Please indicate any other information you would like us to know about this training:
TRAINING COSTS:
- 1 Hour – $600
- 1.5 Hour – $1,000
- Half Day – $2,000
- Full Day – $3,500
Travel time will be billed @ $75 / hour
Training Payment
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
2 digit month, 2 digit day, 4 digit year
Questions or concerns? Contact: education@medainc.org
Should be Empty: