Speaker Request Form

Thank you for your interest in having Helen Archontou, MSW, LSW as a speaker at your event. Please complete as much information as you have about this engagement and speaker requirements.

Event Organizer

Organization

Website

Name of Coordinator/Point of Contact

Contact Email

Contact Phone Number

Contact Position

Event Details

Program Title

Program Description

Program Date

Program Start Time

Program End Time

Program Location

Budget

Proposed Topics

Time of Speakers Presentation

Presentation Format

If other, please specify

Audience

Approximate Size of Audience

Audience Composition/Demographic

This event will be

Will this event be recorded?

Will there be media coverage?

If yes, who?

Additional information

Written Materials/Biography

Due Date for Written Materials & Biography

Offer of Payment/Reimbursement

If other, please specify

How did you hear about us?