*1.First Name(Required.)

*2.Last Name(Required.)

3.Title

*4.Email Address(Required.)

*5.Organization(Required.)

*6.Event (i.e., annual conference, regional meeting)(Required.)

*7.Type of Training(Required.)

Live/In-Person

Remote Webinar

*8.Location of the Event Including City and State (Type N/A if virtual.)(Required.)

*9.Event Date and Time(Required.)

*10.Estimated Attendance or Event Attendance Cap

Note: Due to the number of requests the CDP receives, the Center prioritizes requests based on the number of attendees, with a preference for speaking to larger groups. Requests to speak at conferences or events that have larger potential attendees are therefore more likely to be accepted. Please note that if registration/enrollment for an event is significantly lower than initial expectation, the event may be canceled.(Required.)

*11.Training Request

Please indicate which of our current Speakers Bureau offerings you are interested in. If there is a topic(s) that is not listed that you would like for one of our speakers to facilitate, please indicate that here. While processing your request, we will consider the availability and expertise of the our current speakers to determine who may be best suited to lead the training. Speakers Bureau Offerings(Required.)

*12.Funding Allocated (i.e., honorarium, speaker travel/lodging, etc.)(Required.)

Yes

No

13.As a part of this request, is the expectation for CDP to provide CE's for this training? (Please note that the host organization is responsible for arranging and paying for continuing education credits.)

Yes

No

14.Please provide any additional information about your event that would be helpful as we consider your request.