StrokeSafe Speaker Booking Form

Your Organisation Details

Organisation Name

Mailing Street

Suburb

State

Postcode

Organisation Contact Number

Organisation Type

Number of people employed by your organisation

For workplaces and businesses where the talk is for your staff (not clients/residents), there is a fee based on the number of people employed by your organisation not the number of employees attending the StrokeSafe presentation. By submitting this talk request you are agreeing to this fee. For more information and the fee structure please refer to https://strokefoundation.org.au/StrokeSafe .

Event Organiser Contact Details

First Name

Last Name

Position in Organisation

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Presentation Details

Proposed Date 1

Time 1

Proposed Date 2

Time 2

Proposed Date 3

Time 3

Number of People Attending (approx)

Age Range (majority)

Gender

Other details (Eg Specific Speaker or topic requests, information in languages other than English etc)

Is this presentation open to the public or private?

Contact On Day of Event

Tick if contact on the day is same as organiser above, otherwise complete details below

Contact on the Day

Phone

Online Talk

Online talk through Zoom

Venue Details

Tick if venue is the same address as organisation above, otherwise complete details below

Venue Name

Street

Suburb

State

Postcode

Other Venue Details

Other Equipment

1.0 COVID-19 Organisation & Venue Safety Checklist

1.1 COVID-19 safety requirements

	Yes	No	Unsure
Will any COVID-19 unvaccinated people be allowed to attend this presentation?

Please note Stroke Foundation and its volunteers reserve the right to decline attendance at a face-to-face StrokeSafe talk if they do not feel safe.

Unsure - please specify why

	Yes	No	Unsure
Does your organisation, group or the venue have a COVID-19 Safety Plan?

Please note Stoke Foundation reserves the right to decline a booking request if an organisaion/group or venue do not have an appropriate COVID-19 Safety Plan.

If your organisation/group does not have one, please check with your venue and confirm their plan with Stroke Foundation prior. Upon approval your booking will be processed and confirmed.

Unsure - please specify why

1.1 State government guidelines, hygiene & social distancing

	Yes	No
The talk organiser or venue will ensure hand sanitiser is provided to all participants upon entry and exit of the venue.
The talk organiser and venue will ensure social distancing as per your state government guidelines is adhered to in all areas of the venue including waiting rooms.
The talk organiser and venue will ensure your state governments capacity limit restrictions are adhered to.
To support contact tracing, the talk organiser/venue will ensure use of their state government QR code register where mandatory to record the date, attendees first names and contact numbers.
Stroke Foundation will be notified immediately if the group has a suspected or confirmed case of COVID-19.
Will the talk be held in a room isolated from the public?

Yes - I am aware of and up to date with my state government requirements.

Other Information

How did you find out about us?

If other, please list.

Hidden Use Only

	True
Bypass Validation Rules (Account)
Bypass Validation Rules (Contact)
Active (Campaign)

Preferred Email (Event Organiser Contact)

Record Type ID (Campaign)

Name (Campaign)

Status (Campaign)

Campaign ID Lookup Parameter for Feedback Forms (Campaign)

Organiser Feedback Form ID (Campaign)

Speaker Feedback Form ID (Campaign)

Payment Form ID (Campaign)

Covid Checklist Form id

Parent campaign

COVID Checklist Completed

True

By submitting this form, you understand the Stroke Foundation Privacy Policy and are agreeing for Stroke Foundation to contact you.