Intersex Initiative Portland (ipdx)

Application for Speaker's Bureau Program

Name ______

1. Contact Information

Address ______

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Telephone ______OK to leave message? ______

Email ______

2. Demographic & Speaker Preference Information

We use this information to match requests with the available speakers. For example, if we receive a request for a speaker from a church group and if we happen to have a speaker who is a member of that congregation, that would make a perfect match. Please feel free to skip questions you do not feel comfortable with or do not wish to reveal the answer to.

I am...

___ intersex person ___ partner or family member

___ gay/lesbian/bisexual ___ transgender/transsexual/genderqueer

My gender identity is: ______My preferred pronoun is: ______

I was born in the year: ______My occupation is: ______

My racial and ethnic background is: ______

My religious affiliation is: ______

My educational background is: ______

Language(s) beside English: ______

___ I have a car and am willing to drive ___ I am willing to speak to the media

___ I wish to volunteer in other ways in addition to giving public presentations

What kind of audience (e.g. college classroom, local nonprofit, church, etc.) do you prefer to speak to?

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What kind of audience do you prefer not to speak to?

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What other affiliations, skills, knowledge, experiences, or interests do you bring?

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3. Speaking Experiences

Do you have speaking experiences outside of Intersex Initiative Portland?

If so, on what issues/capacity?

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Why are you interested in becoming a speaker for Intersex Initiative Portland?

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4. Availability

Think ahead for the next several months. When are you most likely to be available to do presentation for Intersex Initiative Portland? Check all slots you are likely to be available (it does not mean that you have to be available—we just need to know when you might be).

Mon / Tues / Wed / Thurs / Fri / Sat / Sun
Morning
Afternoon
Evening

5. Training Expectations and Feedback

What do you wish to learn in the training? What kind of information or skills would be most helpful? What are your fears or anxieties—and how can we address that in our training?

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What other questions do you think would be beneficial to have in this application? Do you have any other suggestions about Intersex Initiative Portland in general, or about the speaker training process? If you think of something later, please feel free to email us.

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What Now?

Thank you for your interest in becoming an ipdx speaker. We will contact you as we schedule the next speaker's training. Completion of speaker's training does not necessarily guarantee that you will be on our speaker's bureau; instead, we will have a meeting with you to decide how we will work together in the future. Please feel free to email us at if you have any questions or comments.