MAHEC Programming Form

Please fill in all information as accurately as possible so that MAHEC may better serve you.

 

Please enter today's date.

 
mm/dd/yyyy
 

Please enter which topic your group is interested in (e.g. Medication-Assisted Treatment, Buprenorphine Waiver Training, Treating Pain Safely, Recovery within Reach, etc.)

 
 

Please enter the name of the group MAHEC will present to

 
 

Please enter your name, e-mail and phone number.

 
 

Please enter the onsite contact for the day of the programming if different than program contact.

 

Please enter the proposed date of your event. If more than one date is available or you need to request more than one date enter dates in the additional information field below.

 
mm/dd/yyyy
 

Please enter requested START time for speaker. If more than one time is available enter in the additional information field below

 

Please enter the END time for speaker. Be sure to include breaks and meals if applicable.

 

Please tell us who we will be presenting to.

 

Please enter the complete location of the event.

 
 
 

Please enter any special parking instructions.

 
 

Please enter if any meals will be provided for the speaker at the event.