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Lyme Education Speaker Request Form
Name
*
First Name
Last Name
Email
*
Verify Email
*
Secondary email
Verify Email
Day of Event
*
When will your event take place?
Time of Event
*
What time will your event begin and end?
Alternate Day of Event
When is another day that works?
Alternate Time of Event
When is another time that works?
Type of event (location)
*
What kind of event is this?
select one
In-person
Online/Virtual
Hybrid
Address of Event (for in-person events)
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Is parking available?
For in-person events
Yes
No
Allotted time for speaker
*
30 minutes, 1 hour, etc.
Audience composition
*
Who will we be speaking to?
Please select a topic you would like our speaker to present on:
*
select one
Grant Application
Healing Light Meditation
Lyme Play, The Great Imitator
Stories of Hope
Support Groups
Foods That Help Recover From Lyme Disease
Psychotherapy, Coaching, Journaling
Get Rid of Ticks in Your Yard
Disability Disclosure on Job Applications
Lyme Stats
Lyme Coaching
Financial Assistance
I'm Not Crazy, I'm Sick
Additional info