Speakers Bureau Request Form *Organization *Contact Person *Phone Number(s) *Email *Address *City *State *Zip *County Speaking Location Special Instructions *How did you hear about the Speakers Bureau? Venue Description (Please describe to assist speaker's preparation) Type of Room Classroom Hall Theater Gymnasium Other Size of Room Small Medium Large Extra Large Equipment Available(Check All That Apply) White Board Blackboard SmartBoard Flip-charts PowerPoint Projector w/Computer Microphone/Sound System Information About Presentation and Participants *Date(s) and Time(s) Number of Participants 10-30 31-60 61-100 100+ Age Range *Please describe the participants' general knowledge of HIV/AIDS issues: Minimal Medium Extensive Details *Content of Presentation: Briefly describe the educational goal for the presentation. What themes or topics would you like presented? * Please note - due to expense of administering the Speakers Bureau and honorariums paid to Speakers, Cascade AIDS Project's standard fees for a speaking engagement of 1 to 3 hours are as follows: 1 Speaker: $100 2 Speakers: $150 3 Speakers: $200 If your organization is unable to pay for the speaker request, simply check the box below asking for a subsidized talk - and we will do our best to accommodate you. Yes No
