Speaker Request

*Company Name:

*Main Phone:

*Contact Name:

*Contact Email:

Fax:

Direct Line:

Cell Phone:

*Event Address:

*City:

*State:

Zip Code:

Audience Type:

Estimated Audience Size:

*Contact Person Day of Event:

United Way Representative:

*Handicap Access:

Yes

No

*Event Date:

*Event Time:

Length of Speeches:

Number of Speakers Requested:

Speaker Attire:

Speaker Attire, Other:

Event Type:

Meeting Facility:

If Other:

Presentation Setup:

Podium

Microphone

Projector Screen

Other

Presentation setup, Other:

*Please indicate preferred agencies and/or topics of the speech:

United Way Community Care Fund

Children & Youth
(e.g. Quality early child care & education, School achievement & drop out prevention, Productive & engaged youth and Child protection)

Health & Mental Health
(e.g. Access to health care for the uninsured & low income, Counseling & mental health, Seniors & persons with disabilities; Health , Services & care giving and Safety & wellness)

Crisis, Housing & Stability
(e.g. Crisis services, Homelessness, & housing, Stability services)

United Way Community Initiatives and Citizens Review Process
The Volunteer Center, United Way 211

United Way Member Agencies

*Please provide us with any additional information you feel is important in planning your event:

Cost of Parking:

Can you reimburse parking:

Yes

No