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New York Health Act Speaker Request Form
To request a speaker to discuss the New York Health Act, please fill out the form below with information about the event you are planning.
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* Indicates required question
Your Name
*
Your answer
Email
*
Your answer
Phone
*
Your answer
List Possible Dates and Times for Event
Your answer
Event Location (Town/City, County) (We are currently only doing remote presentations but please provide your location).
Your answer
Event description
Your answer
Expected number of attendees
Your answer
Event Venue
Your answer
Organization hosting event
Your answer
Organizations you will invite to cosponsor the event
Your answer
Will you be charging for admission to the event?
Yes
No
Clear selection
Will you allow the speaker to make an appeal for donations to the Campaign for the New York Health?
Yes
No
Maybe
Clear selection
Are you able to provide an honorarium for the speaker?
Yes
No
Maybe
Clear selection
Are you about to provide funds for speaker travel costs?
Yes
No
Maybe
Clear selection
Are you able to provide overnight housing if needed?
Yes
No
Maybe
Not Applicable
Clear selection
Would you like support from the Campaign for New York Health in promoting the event through emails, texting, and phone banking?
Yes
No
Maybe
Clear selection
Anything else you'd like us to know about your event?
Your answer
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