New York Health Act Speaker Request Form
To request a speaker to discuss the New York Health Act, please fill out the form below with information about the event you are planning.
Log in to GoogleSave your progress。For details
Your Name *
Email *
Phone *
List Possible Dates and Times for Event
Event Location (Town/City, County)
Event description
Expected number of attendees
Event Venue
Organization hosting event
Organizations you will invite to cosponsor the event
Will you be charging for admission to the event?
Remove selected
Will you allow the speaker to make an appeal for donations to the Campaign for the New York Health?
Remove selected
Are you able to provide an honorarium for the speaker?
Remove selected
Are you about to provide funds for speaker travel costs?
Remove selected
Are you able to provide overnight housing if needed?
Remove selected
Would you like support from the Campaign for New York Health in promoting the event through emails, texting, and phone banking?
Remove selected
Anything else you'd like us to know about your event?
Clear form
Do not submit your password through Google form。
This form was created by the Campaign for New York Health。 Report abuse