Presentation Requests

Presentation Request Form

REQUESTOR INFORMATION

Please select the option that best describes your request.

This is my first outreach about this event.I spoke/emailed with a Center staff member and was referred to this form.The speaker has confirmed and asked me to complete this form.

Name of the Center staff member who asked you to complete this form:

Name of the speaker who has confirmed and asked you to complete this form:

CONTACT INFORMATION

Primary contact person at your organization for this request:

First Name

Last Name

Title/role of primary contact person at your organization:

Name of your organization:

Email address:

EVENT INFORMATION

Title of the event for which you are requesting a speaker:

Location of the event (City, State, Country):

Date of the event. If this is a multi-day event, please indicate the specific date for which you are requesting a speaker.

I would like to request the following individual to speak at this event (if you do not have a specific individual in mind, please leave this blank):

Intended audience of this event (size/expertise):

Purpose/goal of this event:

Type of presentation you are requesting (check all that apply):

Keynote	Panel
Plenary	Roundtable
Small Meetings	Web/Video Conference
Other

If other, give more information here:

Length of presentation you are requesting (approximate length in minutes):

Have any other speakers already accepted invitations to speak at this event?

YesNo

Please list any other speakers who have accepted invitations to speak at this event, as well as a brief description of the topics their presentations will cover.

Does your organization have a budget for travel and an honorarium for the speaker?

YesNo

Budget:____________ + Travel Expenses

Will you have support for A/V? If so, please check all that will be available.

PowerPoint/LCD ProjectorSoundVideo

Primary contact person for A/V:

Email address of contact person for A/V:

Additional comments/questions:

The Center on the Developing Child respects your privacy. We will only use the information you provide here to contact you regarding this request for information and any follow-up communication related to it. Please check the box below to confirm that we may contact you for this purpose.

Yes, please contact me regarding this request.

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