Cooper Aerobics Speaker Request Form

Speaker Request for Cooper Experts

Cooper Aerobics is home to a variety of health and wellness experts. We provide speakers—physicians, personal trainers, dietitians, wellness coaches and more—for conferences, meetings and groups of all sizes.

First Name:*	Last Name:*

Title:*

Company Name:*

Street:


City:	State:


Zip/Postal Code:	Country:

Daytime Phone:*

Email:*

How do you prefer to be contacted?*

Phone

How did you hear about us?*

Presentation Specifics

Event Name:*

Location:*

Audience Size:*

Presentation Date:*

Presentation Time:*

Presentation Length:*

Topic(s):*

Budget for Speaker/Travel Expenses:*

Please provide any additional information or questions.