Speakers Bureau / Lunch and Learn Request Form Speakers Bureau / Lunch and Learn Request Form Contact Information Your organization/business name * Street address * City * State * Zip * Contact name * Contact title * Contact phone number * Contact email address * Preferred method of contact email phone Event Description Event Name * Location * building name AND address Date * Time * Are the date and time flexible? * Yes No Length of time available to present * Proposed Topic(s) * Presentation Format (PowerPoint, discussion, round table, etc.) * Type of Audience (parents, staff/employees, youth, etc.) * Approximate size of audience * Additional details (i.e. other speakers will attend, etc.) Other Details Can we publicly promote and include this event on our website and e-newsletter? * Yes No Are you requesting a specific YSB speaker? * Yes No Which YSB speaker would you like to request? Please note that staff availability depends on the date and time of your event. Will this event be recorded or videotaped? * Yes No Will members of the media be at the event? * Yes No Handouts will be copied by * My organization YSB Materials need to be shared before the presentation * Yes No How far in advance do materials need to be shared?