Speaker Request Form

 

IMPORTANT:  Our speaker request intake process will be closed from September 5th through October 28th, 2018 to allow us to focus on our volunteer needs for our largest fundraiser of the year, the Susan G. Komen Dallas Race For The Cure®.  We will not respond to any speaker requests during this time period.  Please plan accordingly and we thank you in advance for your understanding.  To learn more about our Race, please click here

  Contact Information

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Name:

 

 

   

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Question - Required - Event Date




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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Please tell us more about the audience. Please select all that apply.

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Question - Required - Please tell us more about the age of the audience. Please select all that apply.

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(Maximum response 255 chars, approx. 5 rows of text)

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(Maximum response 255 chars, approx. 5 rows of text)

 

(Maximum response 255 chars, approx. 5 rows of text)

 
Question - Not Required - In addition to a presentation, would you be interested in any of the following materials?

 

Please provide a list of minimum 20 audience members.  This information is needed to secure a speaker.  Your commitment to the audience size is needed in order to be respectful of the speaker's time for the event. 

 

The audience name form is required as part of the speaker request process and needs to be submitted atleast two (2) weeks prior to event date. 


Once the speaker request form has been submitted, please provide the audience's first and last name at the link provided below:  http://dallas.info-komen.org/site/Survey?ACTION_REQUIRED=URL_ACTION_USER_REQUESTS&SURVEY_ID=20183

   Please leave this field empty