Thank you for requesting the presence of the SC Campaign to Prevent Teen Pregnancy to speak at your scheduled event. Please complete the form below and allow at least a month's advance notice from your activity date. Fields in RED are required.

Speaker Request Form
Contact Name:
Organization Name:
Street Address:
City:  State:  Zip:
Daytime Phone:  Alt. Phone:
Email Address:
Type of
Speaker Request:		 Keynote
Workshop
Breakout Session
Other
Specify Other:
If a breakout,
how many times is
session repeated?

Please note that the South Carolina Campaign to Prevent Teen Pregnancy requests that a modest honorarium be paid directly to the Campaign to partially offset the cost of our participation. We request an honorarium of $250 (in-state) and $500 (out-of-state) when Forrest L. Alton, Executive Director speaks, and up to $150 (amount is negotiable) when another member of the senior management staff presents. Honoraria for staff (other than Executive Director) will be based on your specific request and situation.
Requested Speaker:
Alternate Speaker:
Presentation Topic:
Presentation Date:  Presentation Time:
Event Location:
Event Address:
Event City:  State:  Zip:
Audience Size:  Presentation Length:

Who is your target audience and the expected number of attendees?
(Enter number for each that apply):

Teens: Youth: Females:
Males: Parents: Professionals:
Other:    

Event Budget:
Media Coverage?

Any additional information that will help us respond to your needs better:
If you have any questions, please contact Cayci Banks
at cbanks@teenpregnancysc.org or call (803) 771-7700.

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©2008 South Carolina Campaign To Prevent Teen Pregnancy