Presentation Request Form

First Name

Last Name

Title

Organization

Phone Number

Email Address

Address for Presentation

Are there any additional directions/specifics for the presenter (parking, door, room number, etc.)?

Which presentation are you interested in? (Please fill out separate requests for each presentation requested as we have different specialists in each subject matter.) Which presentation are you interested in? (Please fill out separate requests for each presentation requested as we have different specialists in each subject matter.) Age Friendly Communities Age Friendly Businesses Age Friendly Blueprint Ageism 101 Ageism for Faith-based Communities Ageism for Healthcare Reframing Aging

What type of presentation are you requesting? What type of presentation are you requesting? In-person Virtual

Who is the contact person who will help with room setup?

Please list three or more potential Dates for Requested Presentation

How many attendees do you expect?

Who is the target audience? (People who are new to Medicare, assisted living staff, people who have low income, etc.)?

Do you have any special requests for the presenter?

Do you have any additional information that would be helpful as we work together to create a wonderful presentation for you and your audience?

Please check all item you can provide of the following Equipment List. For in-person presentations, we will bring items that you cannot provide. Please check all item you can provide of the following Equipment List. For in-person presentations, we will bring items that you cannot provide. Projector Projector Screen Speakers / Audio Microphone Extension Cord Wi-Fi

Wi-Fi Password