Speaker Request
Thank you for your interest in havng 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.

Thank you!
Today's date
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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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