Speaker Engagement Form

ALTSD Speaking Engagement Inquiry Form

Thank you for your interest in having ALTSD at your event! Please complete this form to help us better understand your request and determine availability. We strive to support events that align with our mission to promote the independence, dignity, health and well-being of older adults, people with disabilities, and their caregivers across New Mexico. Given the Office of the Secretary’s availability, an appropriate Division Director or other senior leadership staff may be selected to represent the agency. Please submit your request at least three weeks in advance of the event date to ensure adequate time for consideration and coordination.

Event & Contact Details

Today's Date(Required)

Event Name(Required)

Event Date(Required)

Event Time(Required)

Physical Location or Online Event?(Required)

Physical Location

Online

Event Location(Required)

Street Address City State / Province / Region ZIP / Postal Code

Virtual Event(Required)

Host Organization(Required)

Event Contact Person Name(Required)

First Last

Email(Required)

Phone(Required)

Website(Required)

Flyer or Document upload

Max. file size: 64 MB.

Audience & Purpose

Expected audience size(Required)

Primary audience demographics (e.g. older adults, caregivers, professionals, elected officials)(Required)

Are any specific groups or stakeholders being targeted?(Required)

What is the main goal or objective of the event?(Required)

What key messages or outcomes would you like an ALTSD speaker to help convey? Are there specific topics or themes you’d like to be addressed?(Required)

Speaker Role & Logistics

Requested speaker role (selection: keynote, panelist, opening remarks, moderator, Q&A session, other)(Required)

Requested length of remarks or presentation(Required)

Will the speaker need a visual component? (handout, powerpoint ,etc.)(Required)

Will audio/visual equipment be provided?(Required)

Describe the physical setup of the event (e.g, seated or standing, podium, stage, microphone use)(Required)

Will the event be recorded or live-streamed?(Required)

Will members of the media be present?(Required)

Promotional & Additional Details

Will you need a headshot, bio, or agency logo of the speaker for promotional materials?(Required)

Yes

Is there anything else you’d like us to know about the event or your request?

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