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Speaker Request Form for General Employee Audience

A United Way Partner Agency representative will share information about the impact their agency makes in the community and why their partnership with United Way is so important. A United Way representative will always accompany the speaker in order to give an overview of United Way (if time allows) and answer any questions that may arise. Each speaker will speak for 5 minutes unless otherwise instructed by the company.

Information about the Company/Organization requesting the speaker:
Submitted by*		A value is required.
Today's Date
Company/ Organization Name*		A value is required.
Telephone*		A value is required.
Cell phone (for contact day of meeting)
E-mail
Alternative Company Contact Name
Alternative Company Contact Email
Physical Address*
Driving directions FROM UNITED WAY *(please include specific building, room, security or parking details needed)
United Way Staff Contact or your Campaign Associate:
United Way Staff or Campaign Associate Cell Phone:

Meeting information:
Day of Week*:		A value is required.
Date*
Time*:		A value is required. AM PM
Speaker arrival time:		minutes early
Would you like to view the campaign video? (~5min)		Yes No
In order for the speaker to better prepare their speech, please tell us a little about the audience:
Brief description of audience and any special details:
Audience Size:
Average Age Range of audience:
% Male:
% Female:
Preferences / Employee Interests: Please refrain from requesting specific agencies because we cannot guarantee them due to speaker schedules. If your requested topic or speaker is not available, we will do our best to find another speaker that will fit your needs. Thank you for understanding.
You may choose one or more of the following Education Income Health Safety Financial Stability Homelessness

 

You will receive a printable receipt via email after submitting your request. Once your speaker is confirmed, you will receive another email with contact information for your speaker.