Workshop
Awards
 
 
 

 

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

INSTRUCTIONS:
Please complete this form and fax to (907) 235-1922 or e-mail to howlinghusky@gci.net Leave any information that is not available blank. Once we have confirmed the date(s) you have requested, we will forward an Equipment and Set-up Form to obtain additional information.

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 Phone:    

Contact Person E-mail:    

Contact Person Mailing Address:    

   

Topics:

An Integrated Approach to Childhood Exposure to Violence and Brain Development
A Critical Intersection: Adolescent Brain Development, Exposure to Violence, and Substance Abuse
The Missing Link: Domestic Violence and Public Health
Arctic Inspirations: Rural Women Starting Small Businesses and Creating Personal Success
We're a Team! Children's Workshop on Teamwork and Leadership from a Dog Team's Perspective
   
Other (Please describe):
   
Estimated Audience Size:

Composition of Audience (Check the box that apply):

Clinical/Medical
Education/Schools
Public Health
Law Enforcement
Mental Health
Legal/Attorneys
Substance Abuse
Judicial
Social Work
Parents/Community
Child Care
Other:
Clinical/Medical
   
       

We will respond to your request within 7 work days.
Thank you for your request.