The Greene County Public Health Speakers' Bureau facilitates requests for speakers on several different public health topics. To request a presentation, please complete the form below and it will be submitted to Laurie Fox at lfox@gcph.info

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 email or phone call accepting or declining your invitation within 7-10 business days of submitting the request.

IMPORTANT: Most of our Speakers’ Bureau presentations have been prepared for general community audiences. If you require a presentation that’s intended for health professionals and other clinical audiences, please make a note of this in the comments section and provide specific information about the audience type. Once again, submitting a request does not guarantee a presenter can attend your event.

Contact Information (Person Completing this Form)
Last Name:
First Name:
Date Date / MM / DD YYYY
Phone Phone - ### - ### ####
Email
About Your Organization
Group Name
Street Address
Zip Code
About the Event
Name of Event
Date of Event Date of Event / MM / DD YYYY
Street Address
City
Zip Code
Event Location

Event Location Indoor Outdoor Both
Expected Number of Attendees
Length of Speaker Talk/Presentation
Speaker Arrival Time
Special Consideration for Parking
Description/Purpose of Event
Indicate Equipment Available:

Indicate Equipment Available: Access to Wifi Access to Electricity LCD Projector Extension Cord(s) Wireless Presentation Clicker Computer with Presentation Software Other Other
Any Other Information That May Help Clarify Your Request
What Topic Would You Like GCPH Staff to Address in the Presentation? (Please be Specific)
Who is your Audience (Please check all that apply)

Who is your Audience (Please check all that apply) General Community Members LGBTQ Men Women Veterans Incarcerated Homeless Elementary School Middle School High School College/University Healthcare Professionals Other Other
Age Range of Your Audience

Age Range of Your Audience Infant/Toddler Children Teens 13-18 Young Adults 18-25 Adults 25-55 Seniors 55+
Cultural/Ethnic Background of Your Audience (Please check all that apply)

Cultural/Ethnic Background of Your Audience (Please check all that apply) African American/Black Asian Caucasian/White Latino/Hispanic Native Alaskan/American Indian Native Hawaiian Pacific Islander Other Other
Please provide any additional information about your audience