This Is Public Health Ambassador Program: Speaker Request Form

  • Thank you for your interest in having a This Is Public Health Ambassador present at your institution. In order to help us facilitate your request, please complete and submit the following form at least two weeks prior to the event, and allow 3-5 business days for us to process your submission. If you have any questions or need help completing the Ambassador Request Form, please call our office 202.296.3021.

  • (Virtual presentation, lecture, roundtable, panel, hands-on activities, etc.):
  • MM slash DD slash YYYY
  • :
  • (30 minutes, 1 hour, etc.)
    Reimbursement for local transportation (cab fare, parking). Max reimbursement amount $50. Coordination of reimbursement is between speaker and organization. Inability to provide reimbursement does not automatically disqualify your request.
  • Drop files here or
    Accepted file types: (jpg, gif, png, pdf), Max. file size: 256 MB.
      Please upload any corresponding attachments.
    • * Indicates required field
    • This field is for validation purposes and should be left unchanged.