Houston Speaker's Bureau Form

REQUIREMENT FOR SPEAKER'S BUREAU

Because we rely on a specialized group of dedicated volunteer professionals to fulfill your requests, we ask that you please note the following requirements:

We require 30 days advance notice and are unable to make exceptions due to volume of requests.
Fulfillment of requests is not guaranteed , but we will do our best to accommodate you.
We require a guaranteed minimum attendance of 20 people at your event.
Companies and organizations are limited to one speaker in a 12-month time period .
If we are able to fulfill your request, we will give you the volunteer speaker's contact information and ask that you be responsible for getting in touch with the designated speaker with details on location, date, time, topic, etc.

Please fill out the form below to request a speaker at your next event in the Houston area.

Name*

First Name Last Name

Address 1*

Address 2

City*

State

Zip Code*

Day Phone*

- Area Code Phone Number

Night Phone*

- Area Code Phone Number

E-mail*

Event Date*

/ Month / Day Year

Event Time*

: Hour Minutes

Location*

Location City*

Event Purpose

Type of Event

Topics for discussion: Please select one.*

Heart Attack and Stroke - Prevention, early warning signs and rehabilitation. Women and Heart Disease - Warning signs, prevention and special effects. Minorities and Heart Disease - African-Americans and why they are at risk; Hispanics and why they are at risk; Heart disease, diet and diabetes. Research - New discoveries; Medical innovations and breakthroughs. Fitness - Benefits of exercise, how to get started and how to persevere for the long-term. Nutrition - How to prepare heart-healthy meals, weight control, exercise and sodium reduction. Cholesterol and High Blood Pressure - What it is, what causes it and how best to control it. Smoking - How it affects your body, how it affects those around you and how to control it.

Requested length of presentation:

Expected Attendees (A minimum of 25 attendees is required to submit a request.):

Audience Description:

Is audio/video equipment available? If YES, please list.

Yes No

List of audio/video equipment if available

Will media be invited?

Yes No

Will Legislators be invited?

Yes No

Please list media or legislators that will be invited

Is this meeting open to the general public?

Yes No

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