Outreach/Speaker Request

Thank you for your interest in having a SC Autism Society staff member attend your event.  Please complete the form below, and we will contact you as soon as possible.

You may also complete a paper copy and mail/fax it to our office.  Click here for the paper form.  Please return to 806 12th Street, West Columbia, SC 29169, Fax: 803-750-8121.

Date of Event:
Start Time:
End Time:

Event Title:
Event Address:
Name of Sponsoring Organization:
Contact Person:
Email Address:
Office Phone:
Cell Phone:

Is the request for a: Keynote SpeakerGuest SpeakerInformation Table

Theme of event or topic of discussion:
Title of speech, if applicable:
What is the expected talk time?
Who is the audience?
How many members/guests are expected to attend?
Are other speakers/officials attending the event? YesNo
If so, what are their names?
Please specify parking location in proximity to event:
Will tables/chairs be provided for information table? YesNo
What audio-visual equipment is available?
Additional information: