PLEASE NOTE: this form is for booking AsIAm speakers for general events around autism awareness across a range of different settings and audiences. If you wish to book an Secondary School Workshop for Autism, please fill out this form instead. Book a Speaker Point of contact informationFirst Name*Surname*This Form must be completed by a staff member who has their management's permission to formally request an AsIAm speaker. Please select your position (or most relevant) below)Job Title*Select . . .PrincipalVice-PrincipalTeacherResource TeacherSpecial Needs AssistantGuidance CounsellorSENOOtherEmail Address* Phone Number*Address Line 1*Address Line 2*Address Line 3Address Line 4City/Town*Workplace InformationWorkplace Name*Address Line 1*Address Line 2*Address Line 3Address Line 4City/Town*County*Select CountyCarlowCavanClareCorkDonegalDownDublinGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklowEircode/PostcodePhone Number*Email Address* Manager's Name*Is this application approved by the managment and/or relevant personnel?*YesNoDates & TimePreferred month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberPreferred day*MondayTuesdayWednesdayThursdayFridayThis will enable us to see if we can match a local speaker to your school.Suitable Time*MorningAfternoonEveningNightOur workshops generally last 90 minutes long. please indicate appropriate class times on the days you have indicatedEvent SpecificsDoes your workplace have a sensory space for autistic employees and or clients?YesNoApprox how many autistic individuals work at your business/organisation?123456789101112131415161718192021222324252627282930Other InformationWhy do you want to receive AsIAm Autism Accreditation for your business/organisation?*Raising awareness of autism among the communityPart of celebration (e.g. Diversity Week, Autism Awareness Month, etc)New autistic colleague(s)’s arrivalBetter engagement with clientele base’s needsOtherWhere did you hear about AsIAm's Speaker Programme?*AsIAm websiteLocal support groupNewspaperSocial mediaWord of mouthOtherCAPTCHAUntitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice This iframe contains the logic required to handle Ajax powered Gravity Forms.