East Central Division Voices Of Hope Request

When possible, all speaking requests should be made at least one month prior to the event

Date Of Event

* +

Select Your Region (see link for map below) *

Voices Of Hope Requested (we will do our best to provide you the speaker you requested)

Speaking Request Contact

(Person who should be contacted regarding this request)

First Name *

Last Name *

Phone Number *

Email Address (to add multiple email addresses separate each with a comma) *

Event Information

Type of event *

Event name *

County & State event is located in *

Location/Address of event *

Event audience *

Audience size *

Length of speech requested *

Details about venue (microphone, seating, inside, outside etc) *

What would you like speaker to base their speech around? (personal journey, ACS patient services, etc) *

Type of dress for event *

Relay Casual

Business Casual

Business

Should speaker remain at event after speech? If YES, what activities will there be for speaker to take part in? *

Additional comments *