URMC / Center for Community Health & Prevention / Education, Talks & Events / Got Health? Talks / Speaker Online Request Form Speaker Online Request Form Contact Information Group/Organization Name: Name: Phone Number: ( ) - Second three digits Last four digits Email: Presentation Topic What topic or information are you interested in having the Center for Community Health present? Please select the topic that is of interest at this time. One topic per request. Nutrition Facts & MythsGluten Free DietsSugar SubstitutesHealthy Holiday EatingLet’s Move for Better HealthMuscle StrengtheningPreventing InjuryWinterize your WorkoutE-Cigarettes & “Vaping”Getting the most from your Doctor’s AppointmentsCancer Prevention & Screening can Save Lives (can cover breast, cervical, ovarian, and colon cancer in English or Spanish)Other I am interested in the following health topic: Event Information Name of Event: Type of Event: Start Date: Calendar End Date: Calendar Suggested Times (ex. 1 pm-3 pm): Location Address 1: Address 2: City: State: Zip Code: Approximate number of attendees 10 20 30 40 50 60 70 80 90 100+ Do you have A/V equipment available in the space to accommodate PowerPoint? YesNo Is there any additional information you can provide?