Holocaust and Human Rights Education Center


Holocaust Survivor Speaker Request Form

This form is to be filled out by an adult ONLY. Student requests cannot be processed. Please fill out this form with as much detail as possible. If your school/business blocks outside emails, please offer an alternative email. You will be contacted soon regarding your inquiry. Due to high demand during Yom Hashoah (Day of Remembrance, April/May), we ask that you request a speaker at least 60 days in advance.

REQUESTOR'S CONTACT INFORMATION
First Name *
Last Name *
Name of Organization *
Position *
Phone *
Email *

EVENT INFORMATION
Date of Event *	// (mm/dd/yyyy)
Start Time *
End Time *
Anticipated Age & Size of Audience *

Location Name *
Street *
City *
State *
Zip *

Any other information we should know?

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Holocaust Survivor Speaker Request Form