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Health Fair/Speaker Request Form

Requests must be received at least 4 weeks prior to the event date. Due to limited resources we are unable to guarantee a Komen representative for your event and request a minimum audience of 20 for speaking requests. It is not our policy to participate in events that charge a fee for non-profit participation.


Contact Information


















Event Details





Question - Not Required - Event Date







Health Fair, Worksite Wellness Events, Other Events



Speaker and Presentation Requests



Question - Not Required - Desired presentation topics


Event Participants


Question - Not Required - Audience Gender (check all that apply)

Question - Not Required - Audience Age Range (check all that apply)

Question - Not Required - Audience Demographics (check all that apply)

Question - Not Required - Will the attendees be: (check all that apply)


Educational Materials



If yes, please indicate the number of each requested, up to a total of 100 items.


Breast Self-Awareness Card





General Breast Health Information Brochure




Men Can Get Breast Cancer, Too




Young Women Brochure




Mammography Card




  If you answered yes to the previous question, where would you like the materials shipped?













If you respond and have not already registered, you will receive periodic updates and communications from Susan G. Komen® Northeast Ohio.


   Please leave this field empty