Speaker Request

Event Primary Contact

Name*

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?*

Yes
No

Day of Event Contact

Name*

First Last

Email*

Enter Email Confirm Email

Mobile Phone*

Event Details

Host Organization*

Type of Event*

Conference
Legislative Event
Rally

Name of Event (please include a brief description)*

Event Start Date*

Event End Date*

Expected Number of Attendees*

Venue Address*

Street Address City State ZIP Code

Overall Topic(s) for discussion/presentation*

Is there a specific bill/legislation that you are fighting?*

Yes
No

Name/number of bill/legislation

Link 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?

Preferred Speaker(s)*

If the preferred speaker isn't available, will you accept another speaker from CHD?*

Yes
No

When do you need a decision on availability of speaker?*

Speaking & Meeting Requests

Date of Speaking Engagement*

Time Slot of Speaking Engagement*

:

Speaker's Role for Speaking Engagement*

Requested length of time for the speaking engagement

Room #

Description*

If a PowerPoint will be used during a presentation, is it acceptable for the presentation to be provided via flash drive?*

Yes
No

If a PowerPoint will be used during a presentation, will a projector and a computer be provided for the speaker?*

Yes
No

Additional Information

Program Information*

Would you like to upload program booklet or provide link to online program?

Upload program booklet pdf
Provide link to program

Please upload the Program Booklet for the Event*

Max. file size: 2 GB.

Link to program*

Schedule Information*

Would you like to upload schedule or provide link to online schedule?

Upload schedule pdf
Provide link to schedule

Please upload the Schedule at a glance for the Event*

Max. file size: 2 GB.

Link to schedule*

Information needed from CHD (please check all that apply)

Speaker Bio
Flight Itinerary
Speaker Headshot

Additional Information and Requests

Logistical Information for Speaker

Please list 1-3 major airports near the hotel where the speaker will be staying*

Is there an existing hotel reservation for the requested speaker?

Yes
No

Hotel where the speaker will be staying

Hotel Address

Street Address City State ZIP Code

Does the hotel have shuttle service to and from the airport?

Yes
No

Hotel is the same as the venue location listed above

Yes
No

Costs Incurred by Speaker

Will all travel and lodging costs for CHD staff be covered by the requester?*

Yes
No

To help offset costs, will there be a fundraising component to the day/night that the CHD representative is in your state?*

Yes
No

Please 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.