Decrease (-) Restore Default Increase (+)
Bookmark and Share
clear spacerWomen's Health

Speakers Bureau Request

* Indicates required information
Your Name  * 
Your Organization/School (if applicable) 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Is this the location of the presentation? * 

If no - where will the location be? 
Primary Phone * 
Alternate/Cell Phone 
Email * 
AUDIENCE 
Check All That Apply * 











If Other, please specify:

Check All That Apply * 


If you have multiple mixed groups, please check all that apply for all your groups. 
Expected attendance * 
Please add any additional information that you think will help us best serve your audience (e.g., demographics, previous knowledge of the topic, etc.) 
PRESENTATION 
If you are requesting more than one presentation on one day -- or would like to schedule a series of presentations -- please elaborate in the "special instructions" box. 
DATE: First preference *  (mm/dd/yyyy)
DATE: Second preference  (mm/dd/yyyy)
DATE: Third preference  (mm/dd/yyyy)
Expected length of presentation * 
Anticipated start and end time * 
Unless otherwise requested, speakers will arrive 25-30 minutes prior to the specified start time of the presentation. 
Special Instructions  
You can also use this box to list additional times (i.e., if you are requesting more than one presentation on the same day.) 
TOPIC 
What will the topic be? * 
Special Instructions 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.
 

OPTIONAL DONATION

Our presentations are free and almost always given by volunteers. While not required, please consider supporting our mission with a tax-deductible donation. Thank you!

Medical Care

Cancer
Pregnancy & Prenatal Classes
Weight Loss
Orthopedics
Heart Disease
Neurology
Women's Health
More Medical Care

Locations

Hospitals
Immediate Care
Health Centers
Emergency Room
Doctors Offices
Specialists
Affiliate Hospitals

Patients and Visitors

MyChart
Pay Your Bill
Request an Appointment
Get Healthy
Support Groups
Fitness Groups
Mobile Applications
Clinical Trials
Online Nursery
Classes and Events
Send an eCard
Patient Stories
Places to Stay
Say Thanks

About Us

Quality Report 
Careers
Ways to Help
Community Outreach
Contact Us
(502) 629-1234

Connect with us

© 2014 Norton Healthcare
Serving Kentucky and Southern Indiana