International Center for the Integration of Health and Spirituality
 
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Programs
  Speakers Bureau Lecture Form

  1. Proposed dates/times for lecture (please provide at least 3):


  2. Expected audience (number of attendees and level of training):


  3. Proposed venue (e.g., regularly scheduled course, conference, departmental grand rounds, etc.):


  4. Degree of current interest and involvement in medicine-religion interface at your medical school, including names and addresses of key faculty in this area (if applicable):


  5. Opportunities (if available) beyond the lecture to meet with participants for further dialogue on this topic:


  6. Your contact information: (Please fill this out as completely as possible. Otherwise we may not be able to contact you due to insufficient information.)

      YOUR NAME:
      YOUR ADDRESS:
      TELEPHONE:
      EMAIL:


You can also download and mail or fax this form to us at:

International Center for the Integration of Health and Spirituality
6110 Executive Boulevard, Suite 908 Rockville, MD 20852
Tel. (800) 580-6447, ext. 301, Fax (301) 984-8143
e-mail: [email protected]

    
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