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Presentation Request Form
Thank you for your interest in our EmpowerEd Program!

Please fill out this form as thoroughly as possible and we will contact you soon.
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Date(s) of Requested Presentation *
MM
/
DD
/
YYYY
Time(s) of Requested Presentation
Time
:
Type of Presentation *
Your Full Name *
Email *
Phone Number *
Organization Name *
Organization Address
Your Position at Organization *
Name of Venue (if different from Organization Name)
Address of Venue (if different from Organization Address)
Location of Presentation (Room Name or Number)
How much time will the presenter have (if not choosing a standard presentation)?
What is the expected attendance? (Please note that the minimum attendance requirement for a ParentEd Conference is 20) *
Will any of these items be available for use? (Check all that apply): *
Required
Any questions, comments, or additional information?
Additional Information
EmpowerEd is a free program offered to the community.  As a non-profit, we receive zero federal funding, so donations are welcome. Cost of average 5 lesson in-person student series (25 students): $600.00.  Cost of average ParentEd Conference: (25 attendees): $400.00.  Donations can be made via check (payable to Options Health) or credit card (www.optionshealth.org/donate)
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