Request for Speaker Form

Please use the form below to request a speaker. If you prefer not to use the form, you can print and submit a PDF version of this form.

Note: If you would like a PowerPoint presentation, please ensure the presentation takes place in a facility with a screen. Also, please confirm at the time of booking whether you require the presenter to bring a projector and/or flip charts.

Organization Name: *

Address: *

City/Town: *

Province: *

Postal Code: *

Contact Person's Name: *

Telephone: *

Email: *

Type of Training Requested: *

FCAS Services: Working with Families

FCAS Services: Foster Care

FCAS Services: Adoption

When and how to report known and suspected cases of child abuse and neglect

What to do if a child discloses abuse to you

The impact of child abuse and neglect on children

The effects of violence on children

How you can help - Volunteering, FCAS Children's fund

Transformation / Recent Changes in our Practice

Other (please specify below)

Other Type of Training (if applicable):

Target Audience (health care professionals, educators, students, etc.):: *

If the target audience is students, what is the age group?:

Date Requested: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year2009201020112012

Time Requested: *

hour123456789101112

:

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am

pm

Type of Presentation Requested: *

Formal presentation (PowerPoint)

Informal (Discussion)

Location where presentation will occur (if different from above):

Number of Participants Expected:

Additional Enquiries or Comments:

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