Request for an Adult Program

Name*
Prefix First Last
Program or Venue Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Preferred form of contact.*
- Phone
- Email
Birthdate
Date Format: MM slash DD slash YYYY
How did you hear about CHS?
If other, please enter how you heard about CHS.
Name of Group*
Age of Group Members*
Number of People in Group*
What type of adult program would you like?*
Preferred date to schedule your program.*
Preferred time for your program.*
Length of presentation.*
- 30 minutes
- 45 minutes
- 60 minutes
How do you want your program presented?*
- Virtually
- In-person
Program Fee*
CAPTCHA