DCH Speakers Bureau

Thank you for considering the Georgia Department of Community Health for your next conference. To request a speaker, please complete and return this form. All fields must be completed for consideration. Those requests with at least a 30-day advance notice will be given priority attention. Someone from the Communications team will follow up with event organizers.

Organization Name (required)

Event Name and Details (required)

Include event title, date, relevant links, and location (below).

Address

City

Postal Code

Event Coordinator

First (required)

Last (required)

Mobile Telephone

Office Telephone

Ext:

Email (required)

Do you have a specific DCH speaker you’d like to request?

Yes

If "yes," then who would you like to request?

What would you like as the topic of discussion? (required)

If uncertain, provide suggestions based on conference themes.

What is the preferred presentation format? (required)

Examples include: keynote; remarks at podium with slides; fireside chat; breakout session, etc.

Who is your target audience(s)? (required)

How many guests are you anticipating? (required)

Will media be invited?

Yes

If "yes," then which outlets?

Additional details or special requests to consider?

DCH Speakers Bureau

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