Name

First Name

Last Name

Phone

(###)

###

####

Program Capabilities

In-person or Online Example: Zoom Presentation

Both In-Person or Online

In-Person Only

Online Only

Program Hosting *

Are you able to RUN/HOST a meeting?

Yes

I would require the club or a 3rd party to host

Do you have a sponsor that will pay for the speaking time?

Yes

No

Sponsor Contact Information

Name of Contact

First Name

Last Name

Phone

(###)

###

####