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Bring a MediaWise Speaker to Your Community!
Fill out this form or call 1-888-672-5437

*First Name:

*Last Name:

*Email Address:

*Organization:

*Address:

Address 2:

*City:

*State:

Zip:

*Contact Phone:

Fax:

Contact name (if different):

*Location of event:

*Date and Time you would
*like the presentation:

*Topics you would like discussed at the presentation:

If Other, please specify:
(Must relate to the Institute's Mission: To maximize the benefits and minimize the harm of the media on the health and development of children and families.)

*Audience Size:

Audience Type (check the primary target audiences):
Educator - Elementary	School Administrators	Parents and/or Caregivers
Educator - Middle School	School Principals	Social Services
Educator - High School	Professional Associations	Business/Community
Educator - College	Healthcare Professional	Faith Based
Early Childhood Professionals	State/Local/Government Agency	Other

If Other, please specify:

Organization Type (check the option that most closely fits your organization/business type):
Educational Institution - Elementary	Community Organization	Healthcare Organization
Educational Institution - Middle School	Youth Serving Organization	State Government Agency
Educational Institution - High School	Local Gov. Entity (School Board, City, County)	Social Services Organization
Educational Institution - College	Parent Organization (PTO, PTA, etc)	Business
Early Childhood/Childcare Provider	Professional Association	Religious or Faith Based Organization
Other	If Other, please specify:

Will this be a: Keynote Workshop

*Length of presentation:

* Check box if open to the public.

Preferred Speaker:

Budget Amount:

Comments/Special Requests:

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