Request a Speaker

Thank you for your interest in the OSF Heart of Mary Speaker's Bureau.

Please submit a speaker request at least three (3) weeks prior to the event date.

* indicates a required field.

Event Name:

Has OSF HealthCare participated in the past?

Event Contact Information

First Name:

Last Name:

Title:

Requesting Organization:

Does the requesting organization have a relationship with OSF HealthCare?

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Contact Phone on Day of Event:
If different from above

Email:

Type of Event:

Event Date:

Presentation Time:

Requested Topic:

Length of Presentation:

Audience Size:

Audience Details:

Event Location 1:

Event Location 2:

Event Attire:

A/V Equipment Available:

Other Notes/Requests:

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