Speakers Bureau Posting Form

IMPORTANT: Checks can be mailed to the following address. Please email PHOTO to partner@bacchusnetwork.org.

The BACCHUS Network™
Attn: Partner Program
P.O. Box 100430
Denver, CO 80250-0430

* Indicates a required field.

* Date Submitted:
* Speaker First Name:
* Speaker Last Name:
* Contact Agency/Organization:
* Street Address:
* City:
* State:
* Zip Code:
* Phone:
* Email:
* Fax:
* Website:
Title of Main Presentation (12 Word Limit)
Titles of Additional Program Presentations (Maximum of 3 – Each a 12 Word Limit)
Bio (100 Word Limit)
Areas of Expertise: (Please select only 2)
Alcohol Diversity Drugs Eating Disorders Impaired Driving Leadership Motivation Nutrition/Fitness Sexual Assault Sexual Health Tobacco Other (2 Word Limit)
Please Indicate Primary Target Audience for Presentations (Please select only 2)
Athletes Gay/Lesbian/Bisexual/Transgendered/Questioning Fraternity/Sorority General Student Audience Graduating Students Health Classes Orientation/First Year Students Men Women Students of Color Other (2 Word Limit)
Please use the electronic signature fields below to indicate that you understand and are in agreement with each of the following statements.
1. The Speakers Bureau will be posted on the main organization website, bacchusnetwork.org.
2. The Speakers Bureau will also be linked from our three other websites smartersex.org, tobaccofreeU.org and friendsdrivesober.org.
3. Speakers Bureau posting to bacchusnetwork.org is for an annual fee of $1,500. Speakers will be listed in alphabetical order by last name and a search function will be provided by health issue and last name.
4. Please keep in mind that speakers who purchase sponsor space on the Speakers Bureau at bacchusnetwork.org should not imply organizational support or endorsement from The BACCHUS Network™ in any printed or electronic promotion or marketing pieces.
5. Sponsorships must be paid in advance of posting.
6. If BACCHUS discontinues a speakers bureau posting before the end of the subscription, a prorated refund for the remaining time period will be provided to the speaker.
* First Name:
* Last Name:
* Date:
The BACCHUS Network Federal ID#: 59-2021675
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