Before filling out a Speaker Request Form, make sure you understand the following:

Our goal is to provide quality breast and cervical cancer screenings at no cost to lower income women in Louisiana. Our focus at events will be to: 1) educate about the importance of screening, 2) inform about our program, and 3) talk with eligible women to help them complete screenings. For speaking engagements, our standard presentation includes information on breast and cervical cancer in Louisiana and LBCHP services (i.e. individual support to complete screenings and diagnostic testing, if needed). If you require additional topics to be covered, please let us know in the “Additional Information” section below.

PLEASE NOTE:  Due to a high demand for speakers, completing a form does not guarantee that we will be able to participate. You will receive an e-mail confirmation if we are able to participate.

If you are having technical difficulties submitting this form, please call 1-888-599-1073 for assistance.

Date of Event *
Date of Event
Start Time of Event *
Start Time of Event
End Time of Event *
End Time of Event
Purpose for LBCHP participation in event – Select the options that describe what you are requesting from LBCHP *
Select all that apply.
Please Provide a driving address along with any other pertinent information such as building or room number.
Please provide parking instructions below:
Contact Name *
Contact Name
Last, First
Contact Phone *
Contact Phone
Number we can call prior to event for more information
Contact Phone on Event Day *
Contact Phone on Event Day
Number we can call day-of event
Please tell us more about the audience. Please select all that apply. *
Please tell us more about the age of the audience. Please select all that apply. *
What items should we bring for the event?
Please include any specific information about your organization that you think will be helpful for the LBCHP representative (background of group, purpose of the event, full agenda)