Requests are accepted from employees of the school/organization that would comprise the audience. Please complete one form per presentation date. Please submit this form at least 3 weeks before the requested presentation date. Fee is $75, payable after the presentation.

School or Organization Name

 

Mailing Address

 

Contact Name

 

Contact Phone

 

Contact Email

 

Requested date of presentation

 

Requested beginning and ending time of presentation

 

Estimated number of attendees

 

Who will the primary audience be? Please select one…
Teachers- elementary
Teachers- secondary
Administrators
School Nurses
Other

 

Address where presentation will take place
(The presentation location will be required to provide an LCD projector and screen.)

 

Why are you requesting a presentation on food allergies? Please select all that apply…
We are experiencing an increasing amount of food-allergic students.
Staff members have requested information about food allergies.
One of our students has experienced an allergic reaction at school.
It was recommended by the parents of an allergic student.
Other

 

How did you hear about the FASGMN Speakers Bureau?

 

Is there any additional information that we may need in planning for you?

 

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