Crouse: A leader in healthcare, a caring community partner.
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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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Community Service Report

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