PIH Speaker Request Form | Partners In Health

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Speaker Request Form

Thank you for your interest in hosting a Partners In Health speaker! We appreciate your partnership. The information you provide on this form will be used to match you with a PIH speaker who best suits your needs.

Requestor Contact Information (required)

Name

Phone Number

Email

Email

Confirm email

Event Details (required)

Are you the event host?

Yes

No

Event Host Name

Event Host Phone Number

Event Host Email

Event Host Email

Confirm email

Event Date and Time

Event Date and Time: Date

Event Date and Time: Time

Event Name

Event Description

Event Address

Address

City/Town

State/Province

ZIP/Postal Code

Event Format

Virtual

In-person

Presentation Length, in minutes

Event Goals

Fundraising

Educational/ Informational

Advocacy

Other

If other, describe the goal of your event

Additional Information

How did you hear about Partners In Health?

Word of Mouth

Advertisement

News Article

Current Donor

Other comments or special requests

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Partners In Health (PIH) is a 501(c)(3)
nonprofit corporation, EIN 04-3567502

Partners In Health, Suite 300,
800 Boylston Street, Boston, MA. 02199
1-857-880-5100 • info@pih.org

PIH® is a registered trademark of Partners In Health.
© 2009-2024 Partners In Health.
All Rights Reserved.

Please send donations to: Partners In Health, PO Box 996, Frederick, MD 21705-0996