SWWI Speaker Request

SWWI Speaker Request

Please fill out the information below if you would like a professional from Mayo Clinic Health System (MCHS) to speak at your upcoming health event. We ask that you submit your request at least six weeks in advance.

If you have any questions please contact the Southwest Wisconsin Community Engagement team at LAComEng@mayo.edu.

Today's Date

Title of Speaking Engagement Opportunity:*

Location & City:*

Date of Speaking Engagement Opportunity:*

Time:*

Contact Name*

Contact Phone Number:*

Contact Email Address:*

Who do you expect to attend the event?*

Consider: age, gender, type of work, etc.

Number of people expected to attend:*

What topic(s) would you like MCHS to cover?*

Is the event open to the public? (Check the box if yes.)

Is there a cost to attend the event? (Check the box if yes.)

What is the format of the event?*

Consider: other speakers, activities, etc.?

Will other healthcare organizatons be present? If so, what is their role?*

Would you like MCHS to provide a display or any materials? If so, please explain.

Has MCHS participated in this event before? If so, please briefly explain our participation*