Speaker Request Form

Organization Name

Type of Organization Type of OrganizationReligiousNon-ProfitCorporateGovernmentEducationCivic/Social/PhilanthropicHealth/Medical/EMSMental Health/Social Work

Contact Name

Contact Email

Contact Phone

Date Requested

Event Start Time

Event End Time

Event Location/Address

Parking Instructions and Cost

Type of Speaker Type of Speaker Keynote Speaker Single Speaker Panelist Table Host Sermon

Please list other panelists

Requested duration of presentation Requested duration of presentationLess than 30 minutes30 minutes1 hour90 minutes3 hoursFull-day training

Estimated number of attendees

Describe the demographics of your intended audience

Any special considerations for your audience?

Technology YOU will provide (check all that apply) Technology YOU will provide (check all that apply) Projector Microphone Speakers Projector screen Computer Other

Other technology from above

Please indicate specific questions or topics you would like us to cover in the presentation.

Will a donation be given to TSW? Will a donation be given to TSW? Yes No

If yes above, what is amount of the donation?

Can a free will offering be taken? Can a free will offering be taken? Yes No

Will transportation costs be reimbursed ? Will transportation costs be reimbursed ? Yes No

Will there be an opportunity to... Will there be an opportunity to... Set up literature table Receive monetary donations Collect in-kind donations (please contact speaker@thesamaritanwomen.org for a current list) Sell product (e.g. TSW biscotti)

Have you been in contact with a TSW staff member? Have you been in contact with a TSW staff member? Yes No

If yes above, please indicate the staff member's name.

Is there a specific TSW staff member requested to speak? Is there a specific TSW staff member requested to speak? Yes No

If yes above, name of speaker

Additional Notes