Request a Speaker
Speaker's Bureau
Request a Speaker
Information about requestor
Organization name:
Contact person:
Address:
Phone:
Fax:
E-mail:
Proposed presentation topic
First choice:
Second choice:
Third choice:
Information about event
Event for which speaker is needed:
Date of Event:
Time:
from
to
Length of presentation:
Number of people expected to attend:
Demographic information (Please describe the people who will attend—men or women, ages, etc.):
Event location/address:
Driving Directions:
What audiovisual resources are available at this facility?
Other information
Does your audience have any special needs?
Please provide any additional information that might help us to determine the best person to work with you.
© 2010
Washington County Health System
251 East Antietam Street
Hagerstown, MD 21740
301-790-8000
TDD: 1-800-735-2258
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