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Online Speaker Requests

Please make speaker requests at least six weeks in advance of the date requested.
Crouse Hospital will attempt to fulfill all requests, but at times may be unable to do so due to speaker schedule conflicts.
The group/organization contact person will be contacted by the Communications Department regarding the status of the request.

Speaker Request

* = Required

* Speaker Topic Requested

* Group/Organization
Making Request

* Group/Organization
Contact Person

* Contact Phone

* Address

* City

* State

* Zip

Anticipated Attendance
at Speaking Engagement

Anticipated Age Range
of Attendees

Date/Time of Speaking Engagement

* Choice 1

Choice 2

Choice 3

* Time

Location of Speaking Engagement

Description of Room Setup For Speaker (e.g., auditorium; dining hall, classroom, etc.)

Audio Visual Equipment Available (e.g., power point projector, overheads, microphone)

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