Clinical Presentation Requests (Speakers Directory Request Form)

CPRI CLINICAL SERVICES Presentation Booking Information

Please complete one form for each request.

Please note that only one request from each organization/agency will be accepted at this time.

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* 1. Where did you hear about the clinical presentations offered by CPRI?

Agency to Agency consultation

CPRI Website

Following a discussion or feedback from a CPRI clinician

From a colleague or employer (option for comment)

From another agency or service provider (option for comment)

Other (please specify)

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* 2. Please select the clinical presentation you would like to request

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* 3. Name:

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* 4. Agency:

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* 5. Please select the region in which your organization/agency is situated

Other (please specify)

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* 6. Address

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* 7. Phone Number

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* 8. Email Address

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* 9. Presentation Date Requested *please provide a minimum of two months notice for your requested date(s)

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* 10. Location

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* 11. Estimated Number of Attendees (Minimum of 30 required)

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* 12. Target Audience (e.g. agency staff, parents, etc.)

Thank you for completing this survey. A CPRI staff will be in contact within 5-10 business days.

Should you wish to express your appreciation for the worth of this presentation, please do so by making a donation to VOCPRI, Volunteer Organization of CPRI (Registered Charitable Organization License #89249 7249 RPR0001) in lieu of a gift or honourarium. You may do so by contacting VOCPRI at (519) 858-2774 or cpri.educate@ontario.ca

Thank you.