Speaker Request Form

Phoenix Holocaust Association/ AZ Jewish Historical Society Speaker Request Form

First Name *

Last Name *

School/Organization Name *

Phone *

Email *

Phone 2

Email 2

Speaker Preference *

Survivors - experiences may include concentration camps, ghettos, hiding, escapes, changed identities, etc.

Descendants of Survivors - the impact of being the child or grandchild of Holocaust survivors; recounting stories of survivors no longer able to speak for themselves

Any available speaker

Audience Age Range/school grade level(s): *

All Ages

Primarily seniors (65+)

Middle school (specify grade level(s) in notes section below)

High school (specify grade level(s) in notes section below)

College

Grade levels if appropriate

Type of Audience *

Secular School

Religious School

Adult Education

Organization

Other

Other, if chosen

Estimated size of audience *

Preferred Presentation Date *

Presentation date is flexible *

Yes

No

Preferred Presentation Time of Day *

If you are requesting more than one presentation the same day, please realize that many speakers are of advanced age and multiple presentations are too taxing.

Time Allotted (including time for questions) *

Presentation Location Address

Address 1 *

Address 2

City *

State/Province *

Zip *

Can your organization/school provides audio-visual equipment (screen, projector connected to computer) *

Yes

No

Possibly

If possibly, please explain

For school/youth audiences, please explain any preparation students have had regarding the Holocaust prior to the date of this requested speaking engagement