COAAA | Online Speaker Request Form

	Note: Required fields are denoted with a red asterisk (). Contact Information Contact Name Organization* County:* Delaware Fairfield Fayette Franklin Licking Madison Pickaway Union Primary Phone* () - Other Phone () - Email* Event Information Please provide preferred date(s) and time(s) when you would like to schedule event(s). Date(s) Time(s) How many will be attending? Where will the event be held? Address Address 2 City State Zip Code Topics Interested in: 3Rs of Medication Management Accessing the Aging Network Be Stroke-Wise Caregiver Workshops Cold & Flu: Hold Your Own Dementia & Communicating with Confused Older Adult Depression and the Older Adult Diabetes: Understanding Causes, Treatment & Prevention Emergency Preparedness: More Than Just a Good Idea Going Green: Where Health & Well Being Meet Grief Smarts! Have I Got a Deal for You! Health Quackery & Other Scams Herbal Remedies: Help or Hype? Humor: Jest for Health Improve Your Eye-Q Maximize Your Memory Medicare 101 Myth, Magic, Fact: Health Information in the 21st Century ‘Oh My Aching’ - Map to Maneuver the Aches and Pains of Aging Putting Health in Motion: Breath Putting Health in Motion: Eat Putting Health in Motion: Move Savvy Senior Safety Sharing Our Stories: The Benefits of Life Review and Reminiscence Skin - The Great Protector Stuff: Tips for Downsizing and Managing Clutter Take Charge! Wellness for Men & Women Tips on Care Facilities Wake Up... to Better Sleep Your Life, Your Choices: Putting it to Paper 60+ Rules for the Road Shared Care: The Point of Doctor – Patient Communication Sensitivity To Aging (paraprofessional groups only) If you are requesting more than one event please specify in comments section below. Comments: Form Submit Please enter the security code from the image.