ACCESS-York & Victim Assistance Center Speaker Request Form

Please complete the following form to notify us of your request and a staff person will contact you to follow up on scheduling. Please note that completion of this form does NOT guarantee that we will be able to provide a speaker.
* required information
Contact 
Contact Person
First Name:*
Last Name:*
Email:*
Address Line 1:*
Address Line 2:
City:*
State:
ZIP/Postal Code:
Phone:
Business Phone:
Speech Specifics
Date of speech:*(mm/dd/yyyy)
Start and end time of speech:*
Name of group requesting speech:*
Location of speech:*
Topics to be discussed:*
Number of people expected in audience:*
Comments/Special Requests/Specific Program Request: