Women's Reproductive Health -- Feminist Women's Health Center

Cliff Valley Clinic • Division of Reproductive Medicine • Community Education & Advocacy Network (CEAN)
1924 Cliff Valley Way, Atlanta, GA 30329 • Clinic: 404-728-7900 • 1 (800) 877-6013 • CEAN/Administrative: 404-248-5445

Photo montage of young women with caption "Leading. Educating. Advocating."

Speaker Request Form

Please fill in this questionnaire to request a speaker. Items in red with an asterisk (*) are required.

* Your Name

* From (group, college, etc.)

* How did you find us?

* email address
(We promise not to give your email address to anyone else!)

*Phone number

Home Work Mobile

Alternate phone number

Home Work Mobile

*Dates & times requested (include back up dates, indicate priority)

Priority	Date	Time

*Location

*Type of Speech Requested (put a check next to appropriate one(s))

Classroom Presentation	Group Presentation	Panel Presentation Participation
Workshop Presentation	Rally Speaker	Conference Presentation
Press Conference Speaker	Other

Are you requesting a Specific FWHC Speaker? (put a check next to appropriate one(s))

Nancy Boothe, Executive Director
Janelle Yamarick, Community Services Director
Specific Department Speaker

* Purpose(s)/Topic(s)?

Expected Attendance? (insert number)

Group Demographics?

*Need Confirmation by (date)

Logistics Provided by Requester (put a check next to appropriate one(s))

Flip Chart Holder	LCD Projector
Laptop Computer	Other

If powerpoint presentation, is it possible to send the presentation to an email address?

Yes
No

Other Information?

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Feminist Women's Health Center
Cliff Valley Clinic * Division of Reproductive Medicine * Community Education & Advocacy Network (CEAN)
1924 Cliff Valley Way, Atlanta, GA 30329
Clinic: 404.728.7900 or TollFree 800.877.6013
CEAN & Administrative: 404.248.5445

The Feminist Women's Health Center is a member of Georgia Shares, an employee giving program.