Speaker Request Survey
First Name
Last Name
State
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Quebec
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Yukon
ZIP Postal Code
Email Address
Communications
Yes, I want to receive email communications from RESOLVE.
Demographic
Please Select Response
I am a friend/family member of someone with infertility
I am a Professional who serves the infertility community
I/We are building my/our familiy and part of the LGBTQ+ Community
I/We have been diagnosed with infertility
I/We have decided to live without children
I/We have resolved and have completed building my family
Other
What is your title?
What is your organization?
Question - Required - Please describe your event:
What is the event website?
What is the event location (virtual, city, state, country, etc.)?
Date of Event:
Why do you want RESOLVE to participate?
Who is the audience?
Expected number of attendees:
Will this event be open to the public?
Yes
No
Will there be a registration fee for attendees?
Yes
No
Indicate specific topic area(s) for RESOLVE content:
What is your Preferred Presentation Format?
Select one
Keynote Address
In-person presentation
Virtual presentation
Panel Moderation
Length of Session/Talk:
Will talk include a Q&A?
Yes
No
Will this event be open to the press?
Yes
No
Who would you like to speak at your event?
Select one
Ayesha Audu
Simmy Bookal
Betsy Campbell
Barbara Collura
Rebecca Flick
Magda Halim
Will there be an honorarium for the RESOLVE speaker?
Select one
Yes
No
Don't know
If travel is required, are travel costs reimbursed?
Select one
Yes
No
Don't know
Has RESOLVE done a speaking engagement with your organization in the past?
Yes
No
How did you hear about us?
Any special requests or comments?
SUBMIT