Organization/School Name

Primary Contact First Name

Primary Contact Last Name

Phone

Email Address

Event Name (if this is a special fundraiser, school event, or other)

Requested Presentation Date(s). Please provide multiple options if your time frame is flexible

Presentation Time(s). Example: 2 - 4 p.m.

Estimated Number of Attendees

Venue Address

Special Instructions (does the speaker need to ring a bell, sign in at the office, etc.)

Is this event a fundraiser for Shepherds of Good Hope? Is this event a fundraiser for Shepherds of Good Hope? Yes No

If so, please tell us about your event / fundraiser

Target Audience (please include age ranges if appropriate)

Will there be audio / visual equipment available for use? Please describe

What topics would you like covered in the presentation?