Leadership Speaker/Attendance Request

Please fill out the form below to request a Lifeline of Ohio Leadership speaker or attendee for your event.

Event Name

Company/Organization Requesting Speaker/Attendee

Date of Event

Event Start Time

Time of Lifeline of Ohio Arrival

Time allotted for remarks

If this is a speaking engagement, please notate how long you would like a speaker for.

Location of Event

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Event Contact Person

First Last

Phone

Type of event

What is the purpose and expected outcomes of this particular event?

What is the expected attendance and audience composition for the event?

Please list topic suggestions for Lifeline of Ohio Leadership remarks

Please list key persons who should be acknowledged