__________

PRESENTATION REQUEST FORM

 

 

 

If your organization is interested in having an educational program presented by FPHS staff, please complete this form and submit it for review. Please send your request at least 4 weeks prior to the presentation event:

Attn: Director of Development and Public Affairs 719 North 3^rd Avenue, Wausau, WI 54401. Thank you!

 

Contact Name: _________________________________________________________________________________________

Title: _____________________________________________________E-mail:_______________________________________

Organization Name: ______________________________________________________________________________________

Address: _______________________________________________________________________________________________

City: _______________________________ State: ________ Zip: _____________ Phone: ( )___________________

 

Presentation(s) topic: ___________________________________________________________________________________

 

Number of presentation(s) requested: __________________ Hour(s) needed to perform presentation(s): _____________

Date(s) Presentation(s) needed: __________________________________________________________________________

Time Presentation is being requested: ______________________ ______________________________________________

 

# of participants: ____________ Participant demographics: ___________________________________

 

Of the following equipment, what is available to FPHS staff to perform presentations (please check all that apply)?

Equipment	Check applicable boxes below	Value (for office use only)
TV/VCR
PowerPoint Equipment (Laptop, Speakers, Projector)
Overhead Projector
Podium
Microphone
Overhead screen pointers
Other (please list)

 

What is the primary reason and/or outcome goal your organization wants to achieve from FPHS performing this presentation?

 

 

FPHS’ presentation fee: $50.00 per presentation.

 

Signature:_____________________________________________________________Date:____________________________

 

Thank you for your commitment to quality, affordable, and confidential reproductive health care issues and for allowing Family Planning Health Services, Inc. (FPHS) to provide education services to your organization. We will contact you shortly.

 

Manager’s Signature: __________________________________ Date: _______________

 

 

 

 

 

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