Application to request a speaker

Virtual Parkland Speakers Bureau provides a variety of healthcare professional speakers who are committed to building awareness through many educational programming efforts. Our professionals help educate, inspire, and motivate individuals throughout the community. This is a free service that covers diverse topics and can be customized to fit the needs of churches, schools, clubs and other community organizations.

To schedule a virtual speaker or request more information, please fill out an application to request a speaker.

Note: Our speakers are well received in the community, therefore, please allow at least a four-six week notice for requests. Participation in your event is based on staff availability.

* indicates required field

Organization & Contact

* Contact Name

* Company/Organization

* Street Address

* City/Town	* State Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
* ZIP	* County
* Contact Email Address	* Confirm Email Address
* Phone Number

* How did you find out about our Speakers Bureau services?
(Please select all that apply)

Email
Event
Family or Friend
Internet Search
Newspaper Article
Phone call
Social Media
Other

If you selected 'Other' above, please specify:

Event Details

* Date of Event

 Time of Event
If the event details are being considered upon the Speaker's availability, you may leave this option blank to indicate that the date/time are "flexible.

Please Select... 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM

* How much time will the speaker have to present?

Select Duration... Less than 30 mins 5 - 10 mins 15 - 20 mins 20 - 30 mins 30 - 45 mins 1 hour 1 - 2 hours Other

Does presentation time include Q&A?:

Is a photo of the speaker needed? (If yes, please specify due date):

Is a biography of the speaker needed? (If yes, please specify due date):

Speaking Engagement: Topic and Format

* Subject/Topic
(e.g. "Eating right, doesn't mean you eat what's left") = Nutrition Education

* Is there an agenda/schedule for the event?
(If yes, please provide a copy to parklandcommunityrelations@phhs.org)

* What is the format of the event?
(e.g. Town Hall, Roundtable, etc.)

Audience Details

* How many people are expected to attend?

Select Number... 10 - 15 15 - 20 20 - 30 30 - 40 40 - 50 50 - 75 75 - 100 100 - 200 200plus Other

If you selected 'Other' above, please specify:

Does your audience have a language preference?
NOTE: most presentations are conducted in English. Some foreign language requests can be met - based on request and speaker availability.

English
Spanish
Other

If you selected 'Other' above, please specify:

* Audience type?

 
(e.g. teachers, nurses, faith leaders)

Other Speaker(s)

* Are there other speakers at this event?

Yes
No

Please specify the names and topics of the other speaker(s) who will be presenting

Speaker Name/Topic

Speaker Name/Topic

Speaker Name/Topic

 

Virtual Support

What online platform will be used? (WebEx, Zoom, Facebook Live, etc.):

Marketing

How is the event being promoted? (social media, radio, etc.):

Additional Information

* Would you like to receive news and updates about Parkland by email?

Yes
No

Is there anything else we need to know about your group/event?
If YES, please explain.

Please enter the letters you see below