Birmingham Holocaust Education Center
Speakers Bureau Request Form

Requester MUST read the Speakers Bureau Guidelines
BEFORE submitting a request.

Contact Information
*REQUIRED FIELDS  
Date*
Requester's Name*
I am a*

  
Name of Group / School*
Group / School Address*
Group / School City*
Group / School State*
Group / School Zip Code*
Group / School Phone  
Requester's Home Phone  
Requester's Cell Phone  
Requester's Email*
*Have you hosted a BHEC speaker before:
If yes, who and when

 

Audience
*REQUIRED FIELDS  
Grade Level / Type of Class*
Size of Group*
* Tell us about your Holocaust Unit and/or goals for this presentation so that we can find the best speaker for you:

 

Preferred Speaking Dates / Times

DATE FROM (time) TO (time)

SPEAKER PREFERENCE  
SPECIAL NEEDS /  
REQUESTS