This Is Public Health Ambassador Program: Speaker Request Form

Thank you for your interest in having a This Is Public Health Ambassador present at your institution. In order to help us facilitate your request, please complete and submit the following form at least two weeks prior to the event, and allow 3-5 business days for us to process your submission. If you have any questions or need help completing the Ambassador Request Form, please call our office 202.296.3021.
Requestor Name:*
First Last
Requestor Email:*
Requestor Phone Number:*
Organization Name:*
Virtual Event?
- Yes
- No
Event Location:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Presentation Topic/Goals:*
Presentation Format:*
(Virtual presentation, lecture, roundtable, panel, hands-on activities, etc.):
Presentation Date:
Date Format: MM slash DD slash YYYY
Presentation Time:*

: HH

MM
Presentation Duration:*
(30 minutes, 1 hour, etc.)
Intended Audience(s):*
Are you able to compensate speaker for cost of travel?*
- Yes
- No
Reimbursement for local transportation (cab fare, parking). Max reimbursement amount $50. Coordination of reimbursement is between speaker and organization. Inability to provide reimbursement does not automatically disqualify your request.
General Comments:
Attachments:
Drop files here or

Accepted file types: (jpg, gif, png, pdf).
Please upload any corresponding attachments.
* Indicates required field
Comments
This field is for validation purposes and should be left unchanged.