Speaker Request Event Primary ContactName* First Last Organization Name*Email* Enter Email Confirm Email Office Phone*Mobile Phone*Is the Primary Contact the same as the "Day of the Event" Contact?*YesNoDay of Event ContactName* First Last Email* Enter Email Confirm Email Mobile Phone*Event DetailsHost Organization*Type of Event*ConferenceLegislative EventRallyName of Event (please include a brief description)*Event Start Date* Date Format: MM slash DD slash YYYY Event End Date* Date Format: MM slash DD slash YYYY Expected Number of Attendees*Venue Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Overall Topic(s) for discussion/presentation*Is there a specific bill/legislation that you are fighting?*YesNoName/number of bill/legislationLink to bill/legislation Sponsor/person who introduced the bill:Major problems or benefits of the bill:*On a 1 to 5 scale with five being the highest likelihood, what is the likelihood that this bill will leave committee this session?*Does the bill have a lot of support?What do you need the CHD speaker/representative to do?Speaker RequestPreferred Speaker(s)*Robert F. Kennedy, Jr., CHD ChairmanLyn Redwood, CHD PresidentIf the preferred speaker isn't available, will you accept another speaker from CHD?*YesNoWhen do you need a decision on availability of speaker?* Date Format: MM slash DD slash YYYY Speaking & Meeting RequestsDate of Speaking Engagement* Date Format: MM slash DD slash YYYY Time Slot of Speaking Engagement* : HH MM AM PM Speaker's Role for Speaking Engagement*KeynoteModeratorPanelistPresenterMeeting ParticipantRequested length of time for the speaking engagementRoom #Description*If a PowerPoint will be used during a presentation, is it acceptable for the presentation to be provided via flash drive?*YesNoIf a PowerPoint will be used during a presentation, will a projector and a computer be provided for the speaker?*YesNo Additional InformationProgram Information*Would you like to upload program booklet or provide link to online program?Upload program booklet pdfProvide link to programPlease upload the Program Booklet for the Event*Link to program* Schedule Information*Would you like to upload schedule or provide link to online schedule?Upload schedule pdfProvide link to schedulePlease upload the Schedule at a glance for the Event*Link to schedule* Information needed from CHD (please check all that apply) Speaker Bio Flight Itinerary Speaker Headshot Additional Information and RequestsLogistical Information for SpeakerPlease list 1-3 major airports near the hotel where the speaker will be staying*Is there an existing hotel reservation for the requested speaker?YesNoHotel where the speaker will be stayingHotel Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does the hotel have shuttle service to and from the airport?YesNoHotel is the same as the venue location listed aboveYesNoCosts Incurred by SpeakerWill all travel and lodging costs for CHD staff be covered by the requester?*YesNoTo help offset costs, will there be a fundraising component to the day/night that the CHD representative is in your state?*YesNoPlease provide details of fundraising component:*Acknowledgement I agree.By selecting box, the requester is in agreement to pay for all of the speaker's costs including travel, meals, and any other possible expenses. Please sign your name below.Name* First Last Job Title*Invoicing Please include who should receive invoicing (usually 30-60 days post event).Name of Organization*Name* First Last Job Title*Email* Enter Email Confirm Email Phone*Thank you for requesting a CHD representative to participate in your event.Your request will be reviewed by CHD staff and you will receive a response within 5-10 business days.
