Howling Husky Homestead - Speaker Request Form

SPEAKER REQUEST FORM
Linda Chamberlain, PhD MPH
35342 Howling Husky Circle
Homer, Alaska 99603

INSTRUCTIONS:
Please complete this form and click on the “Submit Form” button at the bottom of the page. Your request will not be submitted unless you click this button. If you have any questions, please contact us at howlinghusky@gci.net

Conference Name:
Conference Location:
Address:
Town/City:
State:
Zip:

Requested Presentation Date (dd/mm/yy):
Presentation Time Slots (ex: 9-11 am):

Type of Presentation:
Keynote:
Plenary:
Workshop:

Other (please describe):

Name of Contact Person:
Contact Person Office Phone:
Contact Person Cell Phone:
Contact Person E-mail:
Contact Person Mailing Address:

Topics:

An Integrated Approach to Childhood Exposure to Violence and Implications For Early Brain Development

The Amazing Adolescent Brain: Opportunities And Vulnerabilities

The Awesome Teen Brain (For Teens!)

The Hidden Epidemic of Dating Violence:
Recognition, Intervention, and Prevention

Pushing The Prevention Envelope:
What We Need To Do Now To Prevent Domestic Violence

Making The Connection: Domestic Violence and Public Health

Addressing Lifetime Abuse: Pathways For Prevention

Lessons From The Trail On Leadership and Teamwork

Arctic Inspirations: Women Creating Economic Opportunities and Personal Success In Rural Communities

Other (Please describe):

Estimated Audience Size:

Composition of Audience (Check all boxes that apply):

Clinical/Medical

Education/Schools

Public Health

Law Enforcement

Mental Health

Legal/Attorneys

Substance Abuse

Judicial

Social Work

Parents/Community

Child Care

Youth

Clinical/Medical

Other

Please click the “Submit Form” button to complete your request.
We will respond to your request within 7 work days.
Thank you for your request.