Speaking Engagement Request Form

Speaking Engagement Request Form

Name of organization:

Meeting Address:

City:

State:

Zip:

General Topic of the Meeting:

Day and Date of request:
Choice 1: Time:
Choice 2: Time:

Approximate size of group
Number of adults:
Number of children:
Age Range:

Person making the request:

Title:

Street Address:

City:

State:

Zip:

Telephone (Day):

Telephone (Night):

Telephone (Cell):

E-mail address:

Driving instructions to meeting place from Smithtown:

A fifteen-minute video about the Foundation is available. Please indicate if you have facilities for showing a VHS tape.
Yes No

Please note: Transportation for our blind graduates is usually provided by the organization requesting the speaker. We will make every effort to schedule a grduate from your local area.

You will receive written confirmation of your request.

In the event of a cancellation or emergency, please contact the speaker directly as well as contacting the Foundation.

Please click the submit button just once. The application may take a minute to process.