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Every seven minutes someone in America becomes legally blind or visually impaired.

Speakers Bureau Request Form

An * indicates a required field.

Applicant Information

* Contact Name:

* Address:

* City:

* State: * ZIP Code:

* Home Phone:

Work Phone:

Cell Phone:

* Email:

Please give 3 dates and times requested for speaking engagement:

1)   2)

3)

Age of Audience: # Attending:

If this is a school, is this a classroom or assembly setting?

How did you hear of us?

Do you want us to bring a dog?

Do you want us to bring a team (graduate and guide dog?)

Is there a place to display brochures?