Requests Must Be Received 6 Weeks Prior to the Event Date

HEALTH FAIR/SPEAKER/MATERIAL REQUEST FORM

Requests must be received 6 weeks prior to the event date.

Return form via:

Email (preferred method) - or Fax - (773) 444-0071

Event Name:
Date and Time of Event:
(If you do not have a date, please list preferred dates.)
Requesting Organization/Company:
Type of Event: / Health Fair Booth Speaker* (complete additional information below)
Check Presentation Other:
Materials Only** (complete additional information below)
*Materials are available for download at www.ShopKomen.com.
Please give a brief description of your event:
Contact Name: / Contact Phone:
Contact Email:
Contact Address:
(Address, City, State, Zip)
Location of Event:
(If different from contact address.)
(Room #, Address, City, State, Zip)
County of Event:
Number of Participants Expected: / Participant Age Range:
Primary Audience (Check all that apply): Caucasian African American Hispanic/Latino Asian Other
Female Male Survivors
Will the majority of your participants need a language other than English? / No Yes; Language:
If “Yes”, will a translator be provided? No Yes
Is there a fee for the affiliate to participate? No Yes; $
Are you asking other breast health organizations to attend your event? / Yes; Which one(s)?
No
Equipment Provided Free of Charge: / Tables & Chairs LCD Projector/Screen Laptop
TV & DVD/VCR Other:
Please list specific materials, special requests, instructions or additional event details.
* SPEAKER REQUESTS ONLY:
Desired length of presentation:
Topics to Cover (Select all that apply): About SGK Breast Self Awareness Steps Breast Cancer 101 Resources
Other:
** MATERIALS REQUESTS ONLY:
Are you able to pick-up the materials from the Komen Office (8765 W. Higgins Road, Suite 401, Chicago, IL) Yes No
If yes, when will you pick them up? (Pick up times are Mon-Fri, 9am-5:30pm)
FOR OFFICE USE ONLY
Intake Date: / Received By:
Status / CONFIRMED/COMPLETED. Date =
Thank You Sent Post Event Evaluation Form Sent Materials/Equipment Returned
DECLINED. Date =
Ambassador Assigned: / 1) / 2)
3) / 4)
Materials /equipment needed:
Comments:
Contact Dates/Comments:

Updated 12/20/12 SC