Request a Speaker :: Get Involved :: Komen Connecticut - Komen Connecticut provides speakers and breast health information for community events and health fairs.

Contact Information

Requesting Organization
Contact Name*
Contact Title
Contact Email*
Contact Primary Phone*

Contact Mailing Address*
City* State* Zip Code*

Request Information

Response needed by (example: Jan 1 2000)*
Which are you requesting?
Komen informational booth/table at a health fair or education event
Speaker

Additional Information for your Booth

What are the dimensions of the space (table size and number of chairs)?
What equipment will be provided?
The venue is located * Indoors Outdoors
Approximately how many organizations will be present?

Event Information

Title/Name of Event*
Date of Event (example: Jan 1 2000)*
Time of Event (example: 2:00 PM)*

Location of Event (include address, room number or room name): *
City* State* Zip Code*

Is parking provided? * Yes No

If yes please give the exact location of the parking. If no please give the location of the nearest parking. *

Please provide any specific check-in procedures for the Komen representative when she/he arrives at the event:

Please provide any extra information or details we may need to know about the event.

On-site Contact Name*
On-site Contact Phone Number*

About the Audience

Number of Expected Audience Members

Please describe the audience so that we can prepare appropriate materials (gender, ethnicity, % of survivors, education level, age groups, etc.)

Request a Speaker

Contact Information

Request Information

Additional Information for your Booth

Additional Information for the Speaker

Event Information

About the Audience

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