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REQUEST A SPEAKER

After submission, please confirm the form has been received by calling Lisa Lopez at (816) 234-4907.

E-mail:

Name (first and last):

Day phone:

Name of group
(If school, what grade? Grades 6 and up please):

Preferred speaker (if any)

Describe audience:

In which town(s) do audience members reside?
(Please note only if relevant to speaker's topic):

Date of meeting: (xx/xx/xx)

Approx. attendance (at least 20):

Speaker's attendance is requested at what time?
(indicate a.m./p.m.):

Speaker's attendance is required until what time?
(a.m./p.m.):

Meeting location and address:
Depending on the distance outside the metro KC area,
we may not be able to fill your request.

Phone number of meeting location:

TOPIC 1:

TOPIC 2:

TOPIC 3:

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