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It's a New Day in Public Health.

The Florida Department of Health works to protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

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Meeting and Public Speaking Request Form

Contact: Florida Health

Please only submit request that will be occurring within the next 6 months.

Please note, under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

Required fields are marked with an asterisk (*)

Requester First Name: *


Requester Last Name: *


Requester Job Title: *


Requester Email: *


Requester Phone: *


Event Coordinator First Name: *


Event Coordinator Last Name: *


Event Coordinator Job Title: *


Event Coordinator Email: *


Event Coordinator Phone: *


Type of request: *


Date of event: *     (mm-dd-yyyy)


Time of event: *     (24h format)


Organization Name: *


Organization Type: *


Event Address Type: *


Event Address:


Event City:


Event State:


Event Zip/Postal Code:


Event Web Site:


Preferred length/duration of requested speech/presentation in minutes:


Details of Request: *     (Including name of event, link to agenda, etc. Please be as specific as possible.)



Topics of interest to be discussed: *     (Please be as specific as possible.)


Power Point Required? *


Audience type: *     (MDs, lawyers, general public)


Audience of note:  (name & title)


Other Presenters?  (if Yes, details)


Media in attendance? *


Will audience be receiving CME credit? *


Any additional event obligations? *     (if Yes, details)