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Speaker Request Form
Please fill out this form if you would like to have a Maggie's Place staff member speak at your event.
* Indicates required question
Email
*
Record my email address with my response
Group, Organization, or Event
*
Your answer
Date of Event
*
MM
/
DD
/
YYYY
Time of Event
*
Time
:
AM
PM
Time you would like speaker to be there?
*
Time
:
AM
PM
Address
*
Your answer
Organizer Contact Name
*
Your answer
Contact Email
Your answer
Contact Phone Number
Your answer
Any topics you would like us to specifically talk about/highlight?
Your answer
How long would you like us to speak for?
Your answer
Is there a space for us to bring up a powerpoint/video if needed?
Yes
No
Other:
Clear selection
Anything else you would like us to know?
Your answer
Submit
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