* - Required

This request must be received by no later than 30 days prior to the date for which a speaker is requested. We will make every effort to schedule a Speaker for the date requested. You will be notified with confirmation information. In addition, a donation would be gratefully accepted.

* - Required Fields
  *Note: if you would like our organization to attend your health fair, please contact Marilucy Lopes at Mlopes@caringkindnyc.org or call 646-272-2939.
Organization Name*
Type of Organization*
For Profit  
Brief Organization Description (population served, setting, etc.)*
Address where presentation will take place*
Room #
  Floor, Room
Can we send materials in advance?* Yes No
To whose attention (if yes above)?*
Address materials should be sent to?
Date Requested*
OPTIONAL 2nd Date Requested
OPTIONAL 3rd Date Requested
Start Time/End Time*
From: To:
Describe Type of Audience*
Approximate number of attendees expected*
Presentation Objective*
Language Preferred for the Presentation* English Spanish Cantonese Mandarin
Public Transportation
  (Please specify subway and/or bus lines, name of “stop,” number of blocks from transportation stop to organization)
How Did You Hear
About Us?
Contact Person
Phone (day)