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.
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Your Name
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Email
*
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Phone
*
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List Possible Dates and Times for Event
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Event Location (Town/City, County)
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Event description
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Expected number of attendees
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Event Venue
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Organization hosting event
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Organizations you will invite to cosponsor the event
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Will you be charging for admission to the event?
Yes
No
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Will you allow the speaker to make an appeal for donations to the Campaign for the New York Health?
Yes
No
Maybe
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Are you able to provide an honorarium for the speaker?
Yes
No
Maybe
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Are you about to provide funds for speaker travel costs?
Yes
No
Maybe
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Are you able to provide overnight housing if needed?
Yes
No
Maybe
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Would you like support from the Campaign for New York Health in promoting the event through emails, texting, and phone banking?
Yes
No
Maybe
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Anything else you'd like us to know about your event?
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