Speakers Bureau Request (Pre-Event)

Please submit Speakers Bureau requests by completing the form below. Your submission will be reviewed and a member of the Alive Institute team will contact you.

Date of the Presentation +

Alive Hospice Representative/Presenter

Event information

Name of Organization Receiving the Presentation

Please list any additional speakers

Type of Organization

Organization Contact Information

Organization Contact
First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Guest Presenter #1 (if applicable)
First Name

Last Name

Organization

Guest Presenter #2 (if applicable)
First Name

Last Name

Organization

Topics Covered (select all that apply for the date of the presentation) *

Other Topics Covered

Anticipated Length of Presentation (in minutes)

Anticipated Number of Attendees
(Leave blank if unknown)

Materials or Supplies Needed

Brochures (specify quantity and type below)

The Gift Initiative Materials

Other Literature (specify quantity and type below)

Tablecloth

Other Other

Additional Detail

Civic (Rotary, Kiwanis, etc.)	Colleges and Universities
Community Organization/Non-Profit	Corporation
Faith/Religious Group	Funding Source
Health Care Provider	Other Other

Alive Grief Support Services	Care for the Caregiver	Children's Grief
Fundraising	Grief in the Workplace	Health Fair/Trade Show
Hospice 101	Hospice Admissions	Loss of a Child
Loss of a Sibling	Loss of a Spouse	Palliative Medicine
Pediatric Hospice	Student Orientation	Symptom Management
TGI Any Audience	The Gift Initiative 101	The Gift Initiative: Preparing an Advance Directive in 7 Steps
The Gift Initiative: Breaking the Ice	Volunteering	Other Other