top of page


Speaker Summary Sheet

This form is to be completed and returned to the St. Charles County Extension Center by the

speaker. This form may be mailed or delivered in person. Checks are to be made out to University of Missouri Extension

Organization: ____________________________________________________________

Date of presentation: ______________________________________________________

Speaker: ________________________________________________________________

Payment received (Cash or Check and number): ________________________________


Please fill out the contact information below for Extension reporting – if necessary, make your

best guess.

Total Contacts: _______

Male ___ Female ___


Black or African American ___

Native Hawaiian __ or Pacific Islander ___

Causion ___

Two or more races ___

Other ___


University of Missouri Extension

St. Charles County

260 Brown Road, St. Peters, MO 63376

Phone: 636-970-3000 Fax: 636-279-3310

8 a.m. - 4:30 p.m., Monday-Thursday



bottom of page