Speakers' Bureau Registration

Atrium Health Navicent is proud to sponsor a Speaker’s Bureau to provide health education information to the Central Georgia community.

To see a list of topics we speak about, please click here.

To see our Speaker Bureau Guidelines, please click here.

Please complete all areas:

Event Information:

Name of Organization

Presentation Date

Presentation Time

Event Location

Street Address

City

State

Zip/Postal Code

Target Audience

Number of People Anticipated

Topic of Interest

(1 only please)

Goal(s) of this presentation

Contact Information:

Contact Person

Title

E-mail

Phone

Alternate Contact Person

Title

E-mail

Phone

Disclaimer:

I understand this request is for a Medical Center sponsored Speaker's Bureau that needs to be reviewed and approved. This request can be denied for lack of staffing, sponsorship, conflicts of interest/time, or modified according to what can be provided by the Medical Center. I am aware all requests for speakers outside a 25-mile radius from the Medical Center will be denied. I have been notified of the 72-hour cancellation policy and agree to contact the Medical Center if we need to cancel this event. I also understand that if I have not received a confirmation of acceptance by the Medical Center I cannot assume a speaker will be assigned without contacting the Community Health Education Department at 478-633-6349. Please allow a minimum of two or more weeks to process your request.

Electronic Signature:

By typing my name here, I agree that I have read and understand the Speaker's Bureau Guidelines and Disclaimer above:

Signature

Date of Request

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