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Speaker Request

If you would like to request a speaker from Saint Luke Institute, or you would like to partner with Saint Luke Institute to identify and contact a speaker about a particular topic, we are happy to help! Our speakers offer workshops, conference plenaries, and various learning presentations to a variety of audiences. Please complete the form below, including as much information as possible. A member of the Saint Luke Institute team will follow-up with additional details.

NOTE: If you are not able to complete all the information in one sitting, click the “Save and continue later” link at the bottom and you will receive a link which is good for 30 days for you to return and complete your submission.

If you have other questions about requesting a speaker or possible topics, or other needs, please contact us.

"*" indicates required fields

Inquirer Details

Date of Submission (not date of event):*

Enter the date you are completing this form

Name of Inquirer*

Enter the name of the person completing this form.

First Last

Email*

Enter the email address for follow-up contact.

Enter Email Confirm Email

Best Phone*

Enter best phone number for follow up.

Phone Type*

Indicate phone type

Organization / Religious Community / Diocese*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Event Details

Name of Group (if different from above)

Approximate Attendance*

Email Contact*

Enter the email of the best contact for logistics related to the event, including receipt of travel itineraries for speaker, ground transportation, billing, etc.

Enter Email Confirm Email

Is the event on-ground, online or hybrid?*

Will the speaker's presentation be recorded?*

If recorded, indicate how the recording will be used*

Event Start Date*

Enter the date from the calendar of type in in format MM/DD/YYYY.

Event End Date*

Enter the date from the calendar of type in in format MM/DD/YYYY.

Venue Name*

Enter the specific location where the event will be held

Venue Address*

Enter the specific location where the event will be held.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Speaker Request Details

Fees for speakers are determined by number of speakers, length of the event, number of days the speaker(s) are present, online vs. in-person events, and other factors. We will contact you to discuss the details after you submit your form.
NOTE: The host organization is required to cover all travel expenses (airfare or mileage), lodging and meals for the speaker. Expenses not covered directly will be billed. Payment will be due to Saint Luke Institute upon receipt.
We are happy to discuss further details. Please make any notes in the comments field below.

Are you looking for a specific speaker(s)?*

Yes

Enter the speaker's name*

Identify topics / titles for proposed presentation*

Please provide any details that will help us to describe your request to the speaker.

Conference Materials Desired (for On-Ground Events)

Please indicate what items below that the speaker may find helpful to have at the event. We will review these options with the speaker as needed and make arrangements for shipping.

Requested Materials

Amount sent will be determined by total audience information provided above.

Candidate Assessment Brochure

Education Resources Brochure

Intensive Outpatient Brochure

Outpatient Services Brochure

Shipping Address for Venue (if different than above)

If items should be sent to the attention of a particular person or office, please include that information in the Address lines. If it is the same as above, write 'same as above' in the address line.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Comments

Please add any additional comments and notes

Speaker Request

Inquirer Details

Event Details

Speaker Request Details

Conference Materials Desired (for On-Ground Events)

Comments

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