Speaker/Event Request Form

LifeGift is happy to provide speakers on organ and tissue donation for meetings, conferences, health fairs, training and other events. Our speakers include LifeGift staff members, as well as donor family members and transplant recipients. Please provide the following information about your event and any speaker requirements, and a LifeGift staff member will quickly follow up with you. NOTE: Requests must be received at least two weeks prior to the event date.

Name:

Title:

Company/Organization:

Phone:

E-mail:

Event Date:

Event Time:

Event Location/Address:

Event Type:

Event Audience/attendees:

How many people are expected to be in attendance?

What format would you like for the presentation?

Individual speaking with visual presentation
Speaker only (no audio/visuals)
Someone to distribute information on donation
Representative to staff a table at an event (i.e. health fair)
Other:

What presentation topic are you interested in?

Speaker to address the important need for organ and tissue donation, and offer the opportunity to register on the Donate Life Texas Registry
Speaker to share his/her personal story about donation from the perspective of a recipient, donor family or someone on the waiting list
Speaker to give information on the donation process and the Donate Life Texas Registry
Other: