If you would like someone from Children Services to speak to your organization or at your next event, please fill out the the form below. Thank you.

Speaker's Bureau Request Form

Date of Request:                       * indicates required field.
Requesting Organization
* Contact Name:
* Organization:
* Address:
* City: * State:                   * Zip Code:
* Telephone #: E-Mail Address:  
Speaking Engagement
* Date: * Time: * AM/PM
* Topic:
* Location:
* Address:
* City: * State:                   * Zip Code:
Audience
* Who is the Audience:
* Est. # of Attendees:
Facility
Power Point:   Yes         Special Instructions: 
MIC:              Yes         Special Instructions: 
Overhead:       Yes         Special Instructions: