Earthquake Country Alliance: Welcome to Earthquake Country!

Your Contact Information

Name:*

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ZIP Code:

Organization:

Phone number:*

Alternate phone number:

E-mail address:*

Event Details (as much as you know now)

Specific date requested:

OR Date flexibility?

Please give us a general idea, such as "My group meets on the 2nd Tuesdays of each month, and the months of April, August and November are currently available".

Event type*

in-person online

Event start time:

This is your overall meeting start time; enter the ECA presenter start time or exhibit set up time below

Event end time:

Expected audience:

General Audience
Government agency staff
Elected officials
Businesses
Non-profits

Community group
Educators
Youth (elementary grades)
Youth (secondary grades)
Seniors
People with disabilities

Primary language spoken by attendees:

Other language(s) spoken by attendees:

Accommodations for People with Disabilities:

We anticipate people with these abilities to participate:

Mobility disabilities
Visual disabilities
Deaf/Hard of hearing
Cognitive/Intellectual disabilities
Other

Have you arranged for or will you provide (upon request) interpreting or captioning services?

Yes No

Does the site have accessible parking, access throughout the space, and accessible restrooms?

Yes No

Will there be other accommodations?
(Please explain)

Presenter Details (if applicable; exhibitor table details are below)

Presentation start time:

Desired presentation length:

Does that include Q&A?

Yes No

Presentation style:

PowerPoint/video/etc.
Comments only
Panel Discussion
Other

Expected audience size:

Will there be more than one presenter?

Yes No

If yes, please explain above.

Special interest or emphasis desired?

Please tell us if your group has a special interest, such as pet preparedness, the science of earthquakes, or other topics.

Is there a specific presenter you prefer?

Please provide any additional information or submit questions and comments here.