Speaker Request Form

** This form must be completed before a speaker will be assigned to your event. All cancellations are to be made two weeks in advance. Prices are subject to change.

Your Organization

Organization Name:
Name Of Program:
Focus Of Program:
Address:
Detailed Directions To Engagement:

Location

Is your event local?
(within 50 miles of W.O.M.E.N.’s offices)

YES

Complete the following section only if location of engagement is more than 50 miles from downtown Nashville:

Contact person/coordinator provides meals?	YES NO
Select all that apply:	Breakfast Lunch Dinner
Explanation if "NO":
Contact person/coordinator arranges and pays for hotel accommodations?	YES NO
Explanation if "NO":
Contact person/coordinator arranges and pays for airfare(s) to/from your program?	YES NO
Explanation if "NO":
Contact person/coordinator arranges and pays for ground transportation to/from airport?	YES NO
Explanation if "NO":

Contact Details

Contact Person:
Telephone Number:
Fax Number:
Cell Phone Number:
E-Mail Address:
Web Site:

Speaker Requested

Name Of Requested Speaker
(This person must be a volunteer or employed by W.O.M.E.N)

If more than one person is requested, list other names here:

Fees

Speakers' fees can vary. Check with W.O.M.E.N to get exact speakers' prices. An honorarium is not considered to be a speaker's fee.

Will there be a speaker fee paid?	YES NO
Entire amount will be paid by (Date):

Will there be an honorarium paid?	YES NO
Entire amount will be paid by (Date):

Will there be a love offering paid?	YES NO
Entire amount will be paid by (Date):

Donation paid to W.O.M.E.N.?	YES NO
Entire amount will be paid by (Date):

In-Kind donation to W.O.M.E.N.?	YES NO
Items will be offered by (Date):

Event Details

Date(s) Requested:
Time of Engagement:		until

Areas And Topics Of Education Requested

(Please mark items requested)

AIDS 101 Workshop	Human Sexuality	Safe Sex Kits	Professional Training
AIDS general	Substance Abuse	Youth Violence	Financial Workshop
Seniors And AIDS	Tell My Story	Adoption	Two- Or Three-Day Seminar
Women And AIDS	Face To Facts	Cancer Awareness	Youth And HIV/AIDS/STDs
STD Education	Related Brochures
Other (Please describe in the box below)

Services Provided

(Please mark items requested)

	Power Point Presentation (Contact person/coordinator arranges)		Handouts (Contact person/coordinator arranges copies)
	Overhead Projector Presentation (Contact person/coordinator arranges workshop and seminar length)		Workshop
	Other Equipment Needed (Speaker will notify contact person/coordinator)

W.O.M.E.N.'s Products

Speaker can bring agency products for sale:

Books

Tapes

Candles

Table space will be available:

YES

AIDS Memoir: Journal of an HIV-Positive Mother
by Catherine Wyatt-Morley
Kumarian Press, http://www.kpbooks.com
Paperback. 212 pages. Copyright © 1997

Through a series of notes to her children, an African-American mother tells the story of how she learned she was HIV-positive and what that would eventually mean to her children, her marriage, her spiritual development and her work. Refusing to be a victim, Catherine Morley presents a story of how life goes on after AIDS and all the debilitating physical, psychological, and social pains that accompany this dreaded but often misunderstood disease. It separates HIV/AIDS fact from fiction and provides the reader with a glimpse into a world that we must all learn to understand.

Positive People: Combating HIV and AIDS
by Ian Mayo-Smith & Catherine Wyatt-Morley
Kumarian Press, View Details
Paperback. 108 pages. Copyright © 2005

"I was able to read the text during one late evening - very readable with great poems to compliment the text. It is very moving."
-- Geeta Pfau, Assistant Director of Health Services, Eastern Connecticut State University

Filled with personal stories, poems, and memories, Positive People charts the varied experiences of people living with HIV and AIDS. Each person presented in the book shows a unique "face" of the virus, and gives hope that those with AIDS can lead fulfilling, healthy lives. A helpful appendix gives health advice, statistics, and resources. Published by Trafford Publishing

Notes

Notes or special requests not covered:




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