Guest Speaker Request Form

Please fill out the below information and submit at least a month prior to your requested event date in order to give us ample time to secure a Komen representative.

Point of Contact:*

First Last

Email*

Phone*

Event Details

Organization’s Name:

Address of Event:*

Street Address Address Line 2 City State ZIP Code

Date of event:

Speaking Start time:

: HH

MM

Speaking End Time:

: HH

MM

Estimated number of attendees:

Discussion Items:

Select All
Komen Community Impact
Breast Health General Information
Survivor Perspective

Nature of event:

I want a Komen representative to come speak about breast cancer educational information
I want a Komen representative to attend my Third-Party Fundraiser to share breast cancer information
I want a Komen representative to attend my Third-Party Fundraiser to do a check presentation & thank you speech

Please indicate any other details related to the nature of your event:

Event Venue:

Indoors
Outdoors

Items Provided (Please Check All That Apply):

Chairs
Table
Tablecloth
Bathroom Facilities
Refreshments
AV/Projector Equipment

Supporting Materials Requested (Please check all that apply):

Generic
African American
Hispanic/Latino
Men
Young Women
Other

Other:

(Please note speaker will bring Affiliate Information, More Than Pink Walk, and/or related event(s) information at our discretion.)

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Speaker Request Form: