StrokeSafe Speaker Booking Form
Your Organisation Details
Organisation Name
Mailing Street
Suburb
State
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Organisation Contact Number
Organisation Type
Please select...
Community Group
Business or Corporate
Government/Council
Library
Retirement Village or Aged Care
Healthcare (hospital, medical centre, community health centre)
Disability Service or First Aid Provider
Education (school, university, adult learning)
Not For Profit
Community Sporting Club
I am a Community Fundraiser
Other
Event Organiser Contact Details
First Name
Last Name
Position in Organisation
Preferred Phone
Please select...
Home
Work
Mobile
Home Phone
Work Phone
Mobile Phone
Email
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)
Please select...
Under 45
45-64
65 and over
Gender
Please select...
Majority Male
Majority Female
Mixed
Other details (Eg Specific Speaker or topic requests, information in languages other than English etc)
Is this presentation open to the public or private?
Please select...
Private
Public
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
Email
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
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Other Venue Details
Equipment Available
Electronic data projector
Screen
Laptop and speakers
Microphone
Car park for speaker at/near venue
Disabled access and facilities
Other
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?
Please select...
Word of Mouth
Referred by a Friend / Colleague or Another Group
Saw a Media Article
Saw / Heard an Advertisement
Received a Promotional Flyer
Saw it on the Stroke Foundation Website
Mentioned on Another Website
Contacted by Stroke Foundation / Volunteer Speaker
Have had a StrokeSafe Speaker in the Past
Other
If other, please list.
Hidden Use Only
True
Bypass Validation Rules (Account)
Bypass Validation Rules (Contact)
Active (Campaign)
Preferred Email (Event Organiser Contact)
Please select...
Work
Record Type ID (Campaign)
Name (Campaign)
Status (Campaign)
Please select...
Requested
Campaign ID Lookup Parameter for Feedback Forms (Campaign)
Organiser Feedback Form ID (Campaign)
Speaker Feedback Form ID (Campaign)
Covid Checklist Form id
Parent campaign
COVID Checklist Completed
True
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