Speaker or Presentation Request Form

2. Thank you for your interest in having Shelby County Community Services virtually participate in your event. Please complete this form to request our participation.
4. Name of the Program/Event*
6. Organization Sponsoring the Event*
8. Type of Event*

   1. Community Fair
   2. Health Fair
   3. Community Group Meeting
   4. Faith-based Event
   5. Class or Professional Meeting
   6. Radio or Podcast
   7. Other (please specify):
10. Other Event Type*
12. Will there be a video component? Or only audio?*

    1. Video
    2. Audio only
13. Will the presenter have slideshow presenting capabilities?*

    1. Yes
    2. No
15. Platform used to host event*
    Eg: Zoom, Microsoft Teams, facebook live, etc.
17. Access link to event information, if available
19. Name of Location*
21. Street Address*
22. Zip Code*
24. Date of the Event*
    Date of the Event
25. Time of Event*
    Time of Event
26. Start time for presenter*
    Start time for presenter
27. Duration of time for presenter*
29. Expected Attendance*
30. Target Audience*
    case workers, residents, students, professionals, church congregation, etc.
31. Target Area*
    Frayser, Binghampton, zip codes 38111 and 38114, Greater Memphis, West Tennessee, etc
33. Items Provided by the Sponsor*

    1. Table and chairs
    2. Canopy or Tent
    3. Other:
35. Contact Person's Name*
37. Email address*
38. Phone Number*
40. I would like to have someone speak at this event.*

    1. Yes

    1. No
41. Speaker Start Time*
    Speaker Start Time
42. Speaker End Time*
    Speaker End Time
44. I would like for them to speak about:*
46. Check the service(s) below for participation in your event
48. Division of Community Services

    1. information on additional resources available during the Covid-19 pandemic
50. The Aging Commission

    1. serving seniors and adults with disabilities

    Adult day care, meals, home modification or repair, legal assistance, medical equipment, elder abuse prevention, senior centers, state health insurance programs, and transportation
52. Community Services Agency

    1. financial assistance, serving residents trying to break free of the poverty cycle

    Utility and mortgage assistance, medical prescription assistance, family support self-sufficiency program
54. Crime Victims & Rape Crisis Center

    1. serving victims of crimes including domestic abuse, gun violence, sexual assault

    Sexual assault forensic exams and advocacy, counseling, support groups, court appointments, filing for victim’s compensation
56. Veterans Affairs

    1. serving veterans and their families

    Education and training, guaranty home loans, filing claims, burial benefits, educational assistance for dependents
58. The Office of Justice Initiatives

    1. serving residents who face possible incarceration for low level offenses or who have been previously incarcerated and those with mental illness in the system

    Pretrial Services as alternatives to incarceration for low level crimes including youth. Behavioral Health Unit response to residents with mental illness at any stage of the criminal justice system
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field