The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

Speakers' Bureau Community Request Form

Complete this form to request a Speakers' Bureau presentation or Hands Only CPR Training. Please note that presentations are fulfilled on a first-come, first-served basis. Submitting a request does not guarantee a presenter can attend your event. However, submitting three weeks or more in advance will improve our ability to accommodate your needs. You will receive an e-mail or phone call accepting or declining your invitation within 7-10 business days of submitting this request. You will also receive a confirmation number for request tracking purposes.

IMPORTANT: All Speakers' Bureau presentations have been prepared for general community audiences. Once again, submitting a request does not guarantee a presenter can attend your event.

If you are experiencing technical issues using this form, please download the PDF version of the request form and submit it by email to speakersbureau@ph.lacounty.gov.

Thank you!

Today's Date

* must provide value

M-D-Y

1. First Name

* must provide value

2. Last Name

* must provide value

3. Name of Organization

* must provide value

4. Organizaton Street Address

Example: 123 Any Street, Suite 55

* must provide value

5. Organization City

* must provide value

6. Organization Zip Code

* must provide value

7. Phone Number

* must provide value

8. Email Address

* must provide value

9. How did you hear about us?

* must provide value

Department of Public Health Website

Health Education Administration Website

Department of Public Health Employee

Other

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9a. Please specify how you heard about us.

* must provide value

10. What topic would you like us to present at your event?

* must provide value

11. What type of event would you like us to attend?

Note: Please indicate if this is a request for a lecture or a health fair.

* must provide value

Community Meeting

Conference

Health Fair

Lecture

Professional Meeting

Other

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11a. Please specify event type.

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12. Will this event be livestreamed?

* must provide value

Yes

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13. What date are you proposing?

Note: The proposed date must be no sooner than 3 weeks after today. We need to know about the event at least 3 weeks in advance in order to try to accommodate your request.

Due to an increased demand for outreach events during flu season (October-March), you may be asked to reschedule your event.

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M-D-Y

14. What start time are you proposing?

Note: Start time must be during the hours of 8:00AM-6:00PM.

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15. What end time are you proposing?

Note: End time must be during the hours of 8:00AM-6:00PM.

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16. How much time would there be for us to present?

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Less than 1 hour

1 hour

1.5 hours

2 hours

Other

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16a. Please specify how much time there would be for us to present.

* must provide value

17. How many people do you expect will attend your event?

Note: Events with fewer than 20 participants cannot be accommodated.

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18. Who will attend your event?

Note: Check all that apply.

* must provide value

Business Representatives

Community-Based Organization Representatives

College-Age Students

Elementary School-Age Students

Faith-Based Group

Government Agency Representatives

Health Professionals

High School-Age Students

Los Angeles County Employees

Parents

Seniors

Other

18a. Please specify who will attend your event.

* must provide value

19. Is this event open to the public?

* must provide value

Yes

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20. What language do you need for this presentation?

Note: Some materials are only available in English at this time.

* must provide value

English

Spanish

Other

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20a. Please specify language.

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21. Will this event be held via a virtual platform?

* must provide value

Yes

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21a. Please enter the name of the event location.

* must provide value

21b. Please enter the street address where this event will take place.

Example: 123 Any Street, Suite 55

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21c. Please enter the city where this event will take place.

* must provide value

21d. Please enter the zip code where this event will take place.

* must provide value

22. Comments:

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Supervisorial District

SPA

Health District

Census Tract

SPA contact assigned

Request Status

Status Date

Y-M-D

Status Notes

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Final Headcount (actual number of attendees)

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