Speaker Request Form

Address

140 E. Town Street. Suite 1000
Columbus, OH 43215

Contact

614.224.4950

Please fill out the form below about your upcoming events. If you have any questions about the form or need assistance, please contact HPIO’s Manager of Education and Communications Alana Clark-Kirk.

Name of your organization

Organization *

Contact Information

Name

Title

Email Address

Phone

Presentation Information

Date + Time

Location

Expected length of remarks

What topic(s) would you like HPIO to address?

Who is the expected audience?

How many people are you expecting?

Is the presentation part of a conference? If yes, will the presentation be a plenary or workshop session? If workshop, how many other sessions are planned for the same time?

Is the presentation part of a panel? If yes, how many other speakers are participating? What other speakers have confirmed their participation on the panel?

Are you able to provide an honorarium for this presentation?

Yes

Does this presentation require travel from Columbus, OH

Yes

Upcoming ACEs event

The Health Policy Institute of Ohio is partnering with Franklin County Public Health to host a two-part event focused on preventing and mitigating Adverse Childhood Experiences (ACEs).