Speaker request form

A main goal of Women4Change Indiana is to provide accessible education to the community at large on policy and legislative action. Community engagement and outreach is a crucial aspect of reaching this goal, and because of this we are open to share our experiences and ideas to universities, the broader corporate community, policymakers, and organizations that are looking to implement these initiatives.

Please fill out the following questionnaire detailing your request for a Women4Change representative to speak at your conference, class or event. We’ll be in touch with you shortly thereafter.

Name

First Name

Last Name

Organization

Email

Phone

(###)

###

####

Category

Is this event statewide, regional or national?

Event Name

Event Description

Date of the event

MM

DD

YYYY

Location of the event

Size of the event (estimate)

What perspective would W4C add to your event? Are their topics or areas of particular interest you're interested in hearing about from us?

Do you have a specific Women4Change board or staff member in mind to speak?

Will media coverage be involved?

Yes

No

Would you be willing to share our website/social media handles/newsletter to attendees?

Yes

No

Would you provide a donation to the organization in lieu of a speaker honorarium?

Women are often asked to speak and weigh in at little to no cost. An honorarium fee is negotiable, but at Women4Change Indiana we have a policy of paying speakers for their time/expertise to showcase the true value of a woman’s voice.

Yes

No