PurpLE Health Speaker & Training Request Form
Thank you for your interest in collaborating with our team! 
We use the information provided to tailor presentation content and provide an estimated cost for the session. All fees and honorariums are tax-deductible and go towards supporting our non-profit's efforts to ensure free healthcare for GBV survivors and their children. We are sensitive to the budgetary constraints of non-profit and student events and can find ways to collaborate accordingly. 
Thanks again, and please feel free to let us know if you have any questions: Training@PurpLEHealthFoundation.org 

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Name *
Email *
Organization Name *
What service are you requesting? *
Required
PurpLE Health expert you are seeking for event
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How did you hear about PurpLE Health? *
Required
Conference Title (if applicable)
Format *
Topic
 *
Presentation Date and Time *
Presentation Length *
Will there be required preparation or planning meetings?  If so, please provide details on the frequency and length of meetings. *
Will presentation be recorded?  
(Please note, we typically opt out of recordings of trainings and workshops, but are happy to review requests on a case by case basis)
 *
Anticipated Number of Attendees *
Background(s) of Attendees (Ex: Physicians, NPs, Social Workers, Survivor Community Members, Residents, Students, Lawyers, Patient Advocates, etc.) *
Honorarium Amount 
*All honorariums are tax-deductible and go towards supporting PurpLE Health's mission towards advancing health equity for GBV survivors.
 *
For in-person events, please indicate if funding/reimbursement will be available for the following
Any additional information to convey to our team
Submit
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