Speaker Request

Thank you for contacting Susan G. Komen with your speaker request. While we will make every effort to fulfill your request, we cannot guarantee a speaker for your event. Answering the following questions will help us to learn more about your event and expedite the matching process. We thank you for providing as much detail as possible.

Speaker Request Form

First Name(Required)

Last Name(Required)

Email(Required)

Phone

Which category best describes your speaker request:(Required)

Event Name

Event Date(Required)

Is the date flexible?(Required)

Yes

Type of Event(Required)

Is the event type flexible?(Required)

Yes

Event Location(Required)

Presentation topic* (Breast Cancer awareness, Health Equity, survivorship, resources, caregivers, etc.)(Required)

Name of Organization

Event time (include time zone)

Check if time is flexible

Yes

Language, if other than English

Is this a multiple speaker event? (if yes, list other topics and organizations involved)

List any previous relevant presentations this group has received in the past (either from Komen or another Breast Cancer organization)

Engagement Type* (panel, talk, Q&A, luncheon, etc.)(Required)

Engagement Goal (education, awareness, fundraising, etc.)

Engagement Focus* (treatment advancements, genetic mutations, new studies/clinical trials, Komen Scholars/AIS, population science etc.)(Required)

Engagement Length (required attendance time, either entire event or their portion)

Presentation Style (slides, no slides)

Presentation Length (time duration)

Speaker Attendance(Required)

Audience* (size, composition, background, etc.)(Required)

Moderator (yes/no; if yes, who)

Travel (yes/no; if yes, is a budget available to cover costs)

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