Speaker Request Form

Thank you for your interest in engaging with the Department of Health. This page serves as a centralized portal to invite speakers from the Department of Health to speak to your students or staff about:

Public Health Broadly
The Department of Health's Mission, Vision, and Values
The Department of Health's Programs and Services
Career Opportunities with the Department of Health
How to Engage with the Department of Health

1. First Name: *This question is required.

2. Last Name: *This question is required.

3. Title: *This question is required.

4. Email: *This question is required. This question requires a valid email address.

5. Phone Number: *This question is required.

6. School or Institution: *This question is required.

7. School or Institution Address: *This question is required.

8. Please explain your goal in having Department of Health staff speak to your audience: *This question is required.

9. Please explain the focus of your audience. For instance, if this is a class, please specify the area (e.g., Nutrition, Childhood Development, Psychology). *This question is required.

11. My audience is composed of (select all that apply): *This question is required.

Students
Educational Staff (teachers, professors)
Professional Staff (admins, practitioners)
Other

12. If other, please explain: *This question is required.

12. Expected audience size: *This question is required. This question requires a valid number format.

13. Please provide requested dates, date ranges, and times (with time zone) you would need a Department of Health staff member present: *This question is required.

14. Please provide the expected duration of engagement (hour length, number of time-blocks or classes if a school): *This question is required.

15. My audience is at the level of (e.g., high school, 12th grade, college): *This question is required.