Superintendent Speaker Request Form

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Superintendent Request Form

Please complete this form to request the superintendent's engagement at your event. A member of the PCSD Communications team will contact you with additional information. PLEASE NOTE: All required questions must be answered or you will be unable to submit the form.

1.	Event Name*

2.	Purpose of Event*

3.	Organization Hosting Event*

4.	Is this event related to a Poughkeepsie City School District partnership or initiative?*
	Is this event related to a Poughkeepsie City School District partnership or initiative?* YesNo

5.	Date of Event*
	mm/dd/yyyy

Event Start and End Time*

Start
End

7.	Location of Event*

8.	Address of Venue*

9.	Event Contact*

10.	Contact Phone Number*

11.	Alternate Contact Phone Number*

12.	Contact Email Address*

13.	Appropriate Attire for Speaker at Event*

14.	Is PowerPoint A/V equipment available?*
	Is PowerPoint A/V equipment available?* YesNo

15.	What is the role of the superintendent at this event?*

16.	Expected Length of Speech, Comments or Presentation*

17.	Format of Comments (Welcome address, Keynote address, Panelist, etc.)*

18.	Who will be introducing the superintendent? (Name and Title)*

19.	Who else will be speaking at this event?*

20.	If this is a panel, who are the other expected co-panelists? (Please include names, organizations and titles.)*

21.	Please list the key issues the superintendent should address.*

22.	Who is the audience at this event?*

23.	Expected Number of Attendees*

24.	Will media attend?*
	Will media attend?* YesNo

25.	Other Officials or Special Guests Attending*

26.	In the event the superintendent is unavailable, would you like an alternate representative from Poughkeepsie City School District?*
	In the event the superintendent is unavailable, would you like an alternate representative from Poughkeepsie City School District?* YesNo

27.	Additional Comments or Event Notes*

Done

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