American Heart Association Event & Speaker Request Form
Please send form at least 4 - 6 weeks in advance to allow time to process request. Form submission does not guarantee a speaker or staff attendance at requested event.
Organization Name: *
Your answer
Address of Organization: *
Your answer
Event Coordinator Name and Title: *
Your answer
Event Coordinator Phone #: *
Your answer
Event Coordinator Email: *
Your answer
Point of Contact Name (if other than the event coordinator):
Your answer
Point of Contact Phone # (if other than event coordinator):
Your answer
Date of Event: *
MM
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DD
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Start Time: *
Time
:
End Time: *
Time
:
Address of Event: *
Your answer
Type of Event Being Requested: *
Requested Topic: *
Approximate # of attendees: *
Your answer
Audience composition: (check all that apply) *
Required
What language other than English will you be requesting for this event?
Your answer
Is this an annual or first-time event? *
Is this a free or paid event?
Are you working with any other partners? *
If yes, specify who in other field
How will the event be marketed? (check all that apply) *
Required
Where is the event being held? *
Additional event information (ADA accessibility, parking, special vendor instructions, etc) *If food is being provided, please consider using the Food & Beverage Guidelines at www.heart.org/FoodWhereUR
Your answer
What will you be providing? (check all that apply) *
Required
Will we need a certificate of insurance for the event? *
If we can not service your event, would you like educational materials to be sent? (If yes, specify what address you'd like them to be sent in other field) *
Required
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