Civitas Networks for Health Speaker Request Form

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Thank you for your interest in Civitas Networks for Health's participation in your event!

Please fill out the following speaking engagement request form and provide as much information as you have available. We will respond to your request as soon as possible. At least 60 days' advance notice, especially for travel, is appreciated.

Our leadership and team are experts in topics related to health IT, health information exchange, and health improvement policy and programs. They are experienced public speakers and can provide keynote talks, moderate and serve on panel discussions, and facilitate workshops. More information on our team can be found here: https://www.civitasforhealth.org/about/#team

Please note the following terms:

If relevant, Civitas will pay for staff travel upfront per our travel policies and seek reimbursement post-event based on actual costs. Prior to the event the parties will agree upon which items will be eligible for reimbursement.
For keynote sessions or event facilitation, our staff will dedicate extra time and effort to prepare for your event which is why we request a small honorarium, which will be paid directly to the Civitas staff member. The Civitas staff member may request that any honoraria be donated to a charitable cause or organization.

We look forward to participating in your event!

First Name

Last Name

Title

Organization Name

Email address

What is the title of your event?

When is your event scheduled to take place?

Is your event in-person or virtual?

If in-person, where is your event taking place?

If in-person, will you cover travel expenses?

Please provide a link to the event website

Which staff member is your request for?

If someone else, please list name here

What kind of speaking engagement is this?

If a panel, please provide title/description

If keynote, are you able to offer an honorarium?

Are there other invited speakers? Please list.

Who is the audience? How many attendees?

Does the event have a paid registration fee?

Is there anything else we should know?

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