Speakers Bureau 
Speaker Request Form

Please provide the following information in as much detail as possible.

Please Note: For classroom speakers the Center requires a teacher contact who must remain with the students at all times during a speaker's presentation.


Today's Date:

Requester Name:  

I am a:
If other, please specify:

*We regret that the Center is no longer able to accept student requests. We now require an instructor contact for all school or university requests.

Name of Group/School:

School Address (include entire address - number, street, city, state, zip):  

Group/School Phone Number:

Requester's Home Phone:

Requester's Email Address:      

Group/School Fax:

Have you hosted a speaker from our Speakers Bureau before?:

Preferred Speaking Dates and Times:
Please provide specific date and time information if possible. If your schedule is flexible or you can arrange to combine classes with another teacher we recommend the average of 90 minutes be allotted for your speaker.

Speaker Preference:

Age of Audience:

Projected Number in Attendance:

Tell us a little bit about your Holocaust unit and/or your goals for your speaker(s) presentation so that we can find the best speaker for you:


Special Needs or Requests: (please use this section to inform us of any information that we may need in order to make the presentation the best possible one for your intended audience)


How did you first hear about us?