Request for Speaker Form

Subject (Please indicate one or more topics of your choice) Suicide Samaritans - The Organisation
Preferred Date
Preferred Time
Duration of the talk
No. in attendance
Special requests
Facilities (Please indicate which facilities are available)
Overhead facilities Video facilities Wheelchair facilities
School/Organisation
Contact Name
Address
Phone No.
Fax No.

Please feel free to ring our Youth & Community Liaison Officer, Mandy on 9382 3811 if you have any queries. Mandy will contact you directly to discuss and confirm the above details with you.