Book A Speaker

Point of contact information
Title*
First Name*
Surname*
Job Title*
This Form must be completed by a school official / staff member who has the permission of the school management to make a former request for an AsIAm workshop. Please select your position (or most relevant) below)
Email*
Phone Number*
Address Line 1*
Address Line 2*
City/Town*
School information
Name*
Address Line 1*
Address Line 2*
Address Line 3
Address Line 4
City/Town*
Eircode/Postcode*
Phone Number*
Email Address*
Principal Name*
Is this application approved by the School Principle and or relevant personnel?*
- Yes
- No
Dates & Time
Preferred month*
Preferred day*
This will enable us to see if we can match a local speaker to your school.
Suitable Time*
Our workshops generally last 90 minutes long. please indicate appropriate class times on the days you have indicated
Event Specifics
For which school year is the event for?*
How many workshops do you require?*
The maximum number of students per workshop is 40
Does your school have an autism specific class(es)?
- Yes
- no
Approx how many autistic students attend your school?*
Other information
Why do you want to organise an AsIAm workshop for your school?*
Where did you hear about AsIAm's Secondary School Workshops Programme?*
- I confirm that I have read and accept the terms and conditions.
- We store information you give us like your name and email address. We use this data to share personalised content and create a better experience for you. From time to time we will post offers of products and services tailored to you. We will not share your details with third parties. If you agree with our use of your personal information then you can check the box to the left.
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