Presentation Request

* A 14-day advanced notice is preferred to secure a speaker. The earlier your request is submitted, the more likely DARCC will be able to accommodate it.
* To schedule more than one session or training, please complete one form for each event.
* You will receive an acknowledgement of your submission with a copy of your request within 24 hours.
* Unfortunately, we cannot guarantee a specific speaker.
* Alternatively, you may print the request form and submit via email at OR fax to (214) 345-5098.
* Should you have any additional questions, please contact or call (214) 345-5096.

Agency Information:

Date of Submission:



Phone Number:

E-mail Address

Presentation Information:

Presentation Topic (check all that apply)
Sexual Assault AwarenessRoots of Sexual ViolenceSexual HarassmentUnderstanding TraumaPTSD/Rape Trauma SyndromeHistory and Prevention of Sexual ViolenceBystander InterventionCrisis Intervention (youth & adults)Standing up to InjusticeSexual Violence: Defining the Problem and Moving ForwardBreaking the Box: Gender Norms and Sexual ViolenceCustomized prevention programs for Middle School and/or High School YouthOther

If checked other, please use space below to provide further information.

Preferred language of speakerEnglishSpanish

Target Audience of Speaker AdvocatesGeneral Community MembersMedical Care ProvidersClinical/Mental Health ProvidersCJ/Law EnforcementEducatorsGrade School StudentsCollege StudentsFaith-Based Organizations or ChurchOther

If you selected 'Other', please use this space to provide further information:

Estimated Audience Size

First Choice Date and Time

Second Choice Date and Time

Name of Event and/or reason for presentation, if any.

Will table materials be required? (display board, brochures, table cloth, etc.)

If yes, what are the tabling hours requested?

Equipment/Materials available for use at presentation site (check all that apply)
Laptop (Mac/PC)DVD PlayerMicrophoneInternet AccessLCD ProjectorPresentation Paper/EaselTelevisionProjection ScreenDry Erase BoardPA Systems/SpeakersChalkboard

Name of contact person on day of event:

Contact Cell Phone Number:

Building Name and/or Classroom Number:

Street Address, City, Zip Code

Special Parking and/or Security Instructions

Any additional notes:

How did you hear about us?