Speakers Bureau Form

Welcome to the OhioHealth Speakers Bureau

OhioHealth’s Speakers Bureau offers the communities we serve the opportunity to connect with our subject matter experts on a myriad health care topics. We are dedicated to helping you and your organization find the right information and facilitating appropriate speakers to visit and share their expertise. In short, our Speakers Bureau exists to positively impact your community.

Step 1: Complete Organization Information

Organization Information

Organization Name *

Organization Mailing Address

Address *

Address 2

City *

State *

Zip Code *

Step 2: Complete Requester Information

Requester Information

Name *

Job Title *

Email Address *

Phone Number *

Are you an OhioHealth associate? *

Yes

Organization Contact *

Same as requestor information

New Contact (enter below)

Name

Job Title

Email Address

Step 3: Request Information

Speakers Bureau Request Information

I'm interested in: * (select all that apply)

Hosting a Speaker

Other

Name of Program/Event * (Event, program, project, etc.)

Date *

Location/Venue of Event *

Proposed Audience * (number of attendees, demographics, etc.)

Step 4: Desired Topic for Request

Topics (please select)

Behavioral Health

Opioids/Substance Abuse Disorder

Naloxone Training

Stigma with Addiction

Cancer

Screening and Prevention

Cancer Survivorship/Support Services