Speaker Bureau Request Form Today's Date *Name *FirstLastSelect one *TeacherOrganizerOtherIf Other, Please SpecifyName of Group/School *Address Where Engagement Will Take Place *Office PhoneCell PhoneDay of 2nd Point of Contact Name *Day of 2nd Point of Contact Phone Number *Your Email Address *EmailConfirm EmailPlease enter your email, so we can follow up with you.Have you hosted a Holocaust Survivor from Jax Holocaust Survivors Speakers Bureau before? *YesNoPlease specify three dates and a 90 minute time slot for each of those dates. *Age of Audience *Number of Attendees *Teachers, are your students reading Holocaust themed materials prior to the engagement? *YesNoIf yes, which ones? Need suggestions?What are your goals for the presentation?How did you hear about us?NameSubmit If you do not hear from JFCS within a week of submitting this form, contact Gail Furman at 904-394-5723.