Health Fair/Speaker Request

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Health Fair/Speaker Request

Are you interested in a Komen representative visiting your company or organization to do a presentation or participate in your community health fair? If so, please complete the form below. (note: Requests must be received at least three weeks prior to event date)

*1.

Question - Required - Company/Organization Name:

*2.

Question - Required - Contact Person:

*3.

Question - Required - Contact Address:

(Maximum response 255 chars, approx. 5 rows of text)

*4.

Question - Required - Contact Phone Number:

Question - Not Required - Contact Fax:

*6.

Question - Required - Contact Email Address:

(Maximum response 255 chars, approx. 5 rows of text)

*7.

Question - Required - I would like a Komen representative to participate in a:

	Health Fair
	Speaking Event

*8.

Question - Required - Date of event: (request must be submitted at least 3 weeks prior to event date)

Month

Day

Year

*9.

Question - Required - Hours of the event:

10.

Question - Not Required - Location of event if different than contact's address:

(Maximum response 255 chars, approx. 5 rows of text)

*11.

Question - Required - Are you asking any other breast health organizations to be in attendance?

12.

Question - Not Required - If so, please list:

(Maximum response 255 chars, approx. 5 rows of text)

*13.

Question - Required - Audience:

	College Students
	Disabled
	Female
	Male
	Seniors/Elderly
	Spanish Speakers
	Survivors
	Teens

*14.

Question - Required - Estimated Attendance:

15.

Question - Not Required - Please list specific materials, special requests or instructions here:

(Maximum response 255 chars, approx. 5 rows of text)

San Antonio Affiliate of Susan G. Komen for the Cure®
P. O. Box 6678 San Antonio, Texas 78209 · Phone: 210-222-9009 · Fax: 210-222-9766 · Email: info@sakomen.net

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