Speaker Request Form

The CMPD provides gang and violence resistance presentations for youth in all grades, gang awareness and recognition education for adults, and training for all professionals who work with or have contact with youth who are at risk for delinquency populations.

• For information on topics call the Community Outreach Division office at 704.336.7331

• To schedule a speaker, submit an online request form at www.cmpd.org/youthengagement

PLEASE NOTE ... Requests should be made 30 days in advance and will only be confirmed by CMPD'Âs Community Outreach Division.

ORGANIZATION

Organization Name:

Organization Address 1:

Organization Address 2:

Organization City:

Organization State:

Organization zip:

Organization phone:

Organization fax:

Organization website:

CONTACT INFORMATION

Contact Name:

Contact Address 1:

Contact Address 2:

Contact City:

Contact State:

Contact zip:

Contact phone:

Contact fax:

Contact e-mail:

EVENT INFORMATION:

Event Type:

Event Date:

Day of Week:

Time:

Alternative Dates?:

Event Address: (Include building, floor/room #, and parking instructions)

Event Location Phone:

SPEECH INFORMATION:

Topic of Speech:

Audience Information:

Time of Speech:

Length of Speech

Group Size: