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

Due to high demand of speakers, our organization will send representatives to events for 1) clinician education of LBCHP, 2) undergraduate and graduate student (in the health field) education of LBCHP, and 3) community education of LBCHP.  The presentation includes information on breast and cervical cancer in Louisiana as well as our program and services, such as screening and navigation. Our focus at events will be on program education and recruitment. If you require additional topics to be covered, please let us know in the "Additional Information" section below. 

PLEASE NOTE: A completed form does not mean confirmation, as we cannot guarantee certain dates and times. 

Date of Event *
Date of Event
Start Time of Event *
Start Time of Event
End Time of Event *
End Time of Event
Please Provide a driving address along with any other pertinent information such as building or room number.
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
Presentation Capabilities *
Please provide parking instructions below:
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)