ACF CLEAN Proposed Speakers Bureau form AUG25_fnl

ACF SPEAKER BUREAU REQUEST

SPONSOR’S CONTACT INFORMATION
Contact Name:			Organization Name:
Organization Address:
3a. Organization City:		3b. Organization State:			3c. Organization Zip:
Office Number:	Cell Number:			Email Address:
Please give a brief description of your organization:
Public Affairs/Media Contact Name:			Public Affairs/Media Contact Email:
Public Affairs/Media Contact Cell:			Public Affairs/Media Contact Title:

SPONSOR’S ORGANIZATION DETAILS
Name of sponsoring organization:
Website of sponsoring organization:
How is the organization structured?	Type of membership:
How many members are in the organization?
Has your organization engaged in any lobbying activities? 〇 Yes 〇 No
Is your organization planning future lobbying activities? 〇 Yes 〇 No

EVENT DETAILS
Name of Event:
Name of Organization Hosting Event:
Event Location and Venue Name:
Event Type (e.g., Conference/Summit, Briefing, Webinar, Roundtable, Reception, Award):
Venue Street Address:
5a. Venue City:	5b. Venue State:		5c. Venue Zip:
Event Start (At least 60 days out): Click or tap to enter a date.	Event End Click or tap to enter a date.		Open-Ended Event Date:
General Description and Event Purpose:
Indicate and specify and media coverage (i.e., general media and/or trade press, local, regional, print, web, etc.):
Is there a fundraising component to this event? 〇 Yes 〇 No
Is an award, certificate, gift, or other item being presented to the speaker? 〇 Yes 〇 No
Is the event open to the public or invite-only? 〇 Open 〇 Invite
Will you be requesting other ACF employees to speak at this event? 〇 Yes, if yes how many 〇 No
PRESENTATION DETAILS
Date of speaker’s presentation: Click or tap to enter a date.		Type of membership:
Length of Requested Presentation:		Audience and Key Participants:
Speaking Start Time:		Speaking End Time:
Audience Size:		Audiovisual Capabilities: 〇 Yes 〇 No
Type of Participation: 〇 Keynote 〇 Remarks 〇 Round Table 〇 Panel 〇 Fireside Chat 〇 Breakout 〇 Presentation
Is an alternative presentation approach feasible besides an in-person presentation?
Will this meeting be recorded? 〇 Yes 〇 No
Will there be an opportunity for Q&A? 〇 Yes 〇 No		Q&A Duration:

ACF-SPECIFIC INFORMATION

1. Enter the requested ACF employee’s name (If known):

2. Would you be willing to accept an alternate speaker if the individual requested is unavailable? 〇 Yes 〇 No

3. What ACF Office are you requesting? (Select one)

〇 a. Office of the Deputy Secretary (IOAS)

〇 b. ACF Tech

〇 c. Administration for Native Americans (ANA)

〇 d. Administration for Children, Youth and Families (ACYF)

〇 e. Children’s Bureau (CB)

〇 f. Office of Early Childhood Development (ECD)

〇 g. Family and Youth Services Bureau (FYSB)

〇 h. Office of Child Care (OCC)

〇 i. Office of Child Support Services (OCSS)

〇 j. Office of Community Services (OCS)

〇 k. Office of Family Assistance (OFA)

〇 l. Office of Family Violence Prevention and Services (OFVPS)

〇 m. Office of Head Start (OHS)

〇 n. Office of Human Services, Emergency Preparedness and Response (OHSEPR)

〇 o. Office of Planning, Research, and Evaluation (OPRE)

〇 p. Office of Refugee Resettlement (ORR)

〇 q. Office of Trafficking in Persons (OTIP)

4. What is the proposed topic of the requested speaker’s presentation?

5. Deadline to receive speaker confirmation: Click or tap to enter a date.

ADDITIONAL INFORMATION

1. Please attach the request on formal organization letterhead as a PDF or Word document. List ALL required speakers. File attachment cannot exceed 5MB.

2. Please submit a completed agenda with all invited speakers, lobbyists, elected officials, and topics as a PDF, Word document, or online via a web address. Drafts are acceptable. File attachment cannot exceed 5MB.

CERTIFICATION

I certify that I am an authorized representative of the sponsoring organization listed on this form. I understand any falsifications or misleading information is grounds for this request being denied.

☐ I certify the information provided herein.

Please save a copy of the completed form and email it to ACFSpeakerRequests@acf.hhs.gov

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