Speakers Bureau Workshop Request Form

Let Love Heals Speakers share their experiences at your school, organization or event.
Please provide your details below:

Name *
Name
Phone Number *
Phone Number
School or Organization Address *
School or Organization Address
Workshop Location Information (optional)
Workshop Location Information (optional)
Are you requesting a workshop or representatives for a health fair?
Date you are requesting us to attend this engagement:
Date you are requesting us to attend this engagement:
(We are able to accommodate up to 5 presentations on a given day. Please include desired session START and END times.)
The workshop(s) or health fair will take place in a:
What ethnicities are represented in your audience?
(Please check all that apply.)
Will the participants have received any HIV education from your school/program this school year prior to our visit?
Does your school or program serve one or more of the specific groups listed below?
(Please check all that apply.)