Speaker Request
Thank you for your interest in having Pulse Center for Patient Safety Education & Advocacy present to your community, association, school, colleagues or family.  Please complete the following form to be sure all details are recorded accurately.  When done, e-mail icorina@PulseCenterforPatientSafety.org or call (516) 579-4711 to let us know it is complete and allow a day for us to get back to you.  For healthcare professionals please call about fees. The program can not be confirmed until you speak to someone at the organization and all information is complete.

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Name of person completing this form
Phone number of person completing this form
E-mail of person completing this form
If this is for a group or organization, what is the name of the group or organization?
How did you learn about Pulse CPSEA?  Who should we thank?
Date of program
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Is date / time flexible? Comment welcome
Time of program and length of time requested to speak.  Time for Questions?  
Name / title of program
What is the Topic You are Requesting?
Is power point suggested?
Clear selection
How is presentation expected?
Clear selection
Approximate # in attendance
Who are the planned attendees?  The Pulse mission is to educate, advocate for and support patients.  For audiences of 50% or more healthcare professionals, please call about fees.
Do you have a request for  specific speaker?  If so who are you requesting?
Have you spoken to someone already?  If so to whom did you speak?
Pulse is a nonprofit organization and a speakers fee is suggested.  How much is the planned speakers fee?
Please add any additional information that will be helpful to make this program a success
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