Speakers Bureau Form

Council on Aging's Speakers Bureau provides information on a variety of topics of interest to seniors, people with disabilities, caregivers, families and professionals. Use this form to request a speaker, participation in your event, a one-on-one meeting, or COA literature for your business or organization.

Your Contact Information

* First Name

* Last Name

* Email Address

* Confirm Email Address

* Phone

Information About Your Organization

* Organization Name

Website

* Address 1

Address 2

* City

* State

* Zip Code

* County

Information About Your Event or Meeting

* I would like to request:

A Speaker

A Council on Aging information booth for my event

Council on Aging literature (fact sheets, brochures, posters, etc.)

A one-on-one meeting about Council on Aging

* Please describe the topic/information you would like the speaker to cover.

* Please describe all audio-visual equipment that will be available to the speaker (laptop, screen, projector, microphone, etc.)

Event/Meeting Name

* Number of people expected to attend

Event/Meeting Date

Event/Meeting Start Time

Event/Meeting End Time

Is the event outdoors?

Yes

Is this the first year for the event?

Yes

Is the event/meeting open to the general public?

Yes

Event Meeting/Location (if different than the address information you provided above, please provide the location details here):

Additional Event/Meeting Details

* Please describe the audience for this event/meeting:

* How do you plan to advertise/promote the event (local newspaper, organization newsletter, website, social media, etc.)?

* Please provide more information about your organization, the event, and your request:

Yes, I would like to receive your email newsletters

Submit

* required information