Skip Global navigation and goto content

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.

Skip MegaMenu and goto content

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)