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Contact name*

Phone number*

Email address*

Organization name

Address

Possible dates/days of week

Time of day

Amount of time

Location type (e.g., auditorium, conference room, library)

Location Address

Focus of talk

Audience Composition (e.g., parents, teachers, clinicians)

Other comments

Michael Rich-FOSI award

Interested in having a member of the CMCH team speak at an event? Complete the form, and we will respond as soon as possible.

Note that, in lieu of an honorarium, we ask that a donation be made to support CMCH’s work. For more information on the requested donation, please complete the form or email us at cmch@childrens.harvard.edu