Leadership Request

Komen leadership attendance at events is subject to availability, and we are unable to guarantee fulfillment of every request. After submitting this form, you will be notified when your request has been processed and whether a Komen representative will be able to attend.

Fields marked with an asterisk(*) are required.

Event Title:*
Location:*
All Day Event?*
- No
- Yes
Start Time:*
End Time:*
Description of Event:*
History of Event:*
Are any Non-Komen VIPs Attending?*
- No
- Yes
Requester Name:*
Requester Organization:*
Requester Email:*
Requester Phone Number:*
Top 3 Choices for Komen Leadership Attendance:*
Publicity Opportunity:*
Affiliate Integration Opportunity:*
Partner Cultivation/Stewardship Opportunity:*
Notes:
Will the Requesting Organization Pay for Travel Expenses? Please Describe:*
Helpful Information (in relation to the Location):*
Is the Leader requested to Make Remarks?
- No
- Yes
If Yes:
Who is Developing Remarks?
Requested Topic of Speech:
Estimated Length of Speech:
Number of Attendees:
Description of Audience:
Info or Acknowledgements to Include in Remarks: