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COPY_Health Fair/Speaker Request Form

 

Contact Information

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*

Name:

 

 

   

*

 

 

 

City/State/ZIP:

 

    

 

 

 


 

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 (limit 100 total)

 


 


 


 

General Breast Health Information Brochure (limit 100 total)

 


 


 

Mammography Card (limit 100 total)

 


 


 


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

 

Name:

 

 

   

 

 

 

City/State/ZIP:

 

    

 

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