Requestor's Name

Title:

Group / Organization

Address:  City, State, Zipcode

Telephone: (area code and number)

E-mail:

Name of Your Event:

Event Location:                                                                       Event Date:

Audience: (please provide a description of people attending, ie: professional level, education, area of focus...)

Logistics: Type of Engagement:  (circle one )        Breakfast meeting           Lunch Meeting                                                                                   Meeting does not involve food Is the room equipped with LCD projection equipment for PowerPoint Presentation? Is a flip chart / black board / white board available?

Estimated Number of People Attending Event:

Start Time:                                                                                 End Time:

Presentation Topics: (circle one)

1.    Early Childhood Nutrition:  The Vital Period Between Birth and Twenty-four Months

2.    Early Childhood Nutrition:  The Preschool Years

3.    Family Nutrition:  What's In Your Cupboard?

Please describe your goal for those attending this speaking engagement:

Requirements:

1.  All speaker requests must be coordinated through this website or our e-mail address. 2.  The requesting group / organization will be responsible for all travel expenses (travel and hotel if applicable) incurred by the speaker. 3.  Speaker fee varies based on group or session.  Please call or e-mail to discuss our fee schedule.  4.  Please allow a minimum of three weeks for your request to be processed.  Thank you!

Please e-mail a completed copy of this form to americahealthpub@aol.com