2023 Speaker Request Survey

1.	Please fill out the following: * Name: First Name Required  Last Name Required      * Email: Required   State/ZIP: State   ZIP AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NL NS NT NU ON PE QC SK YT None   * Phone Number: Required   Yes, I would like to receive e-mail from RESOLVE: The National Infertility Association   Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers. Privacy Policy
*2.	Question - Required - What is your title?
*3.	Question - Required - What is your organization? (Maximum response 255 chars, approx. 5 rows of text)
*4.	Question - Required - Please describe your event: (Maximum response 255 chars, approx. 5 rows of text)
*5.	Question - Required - What is the event website? (Maximum response 255 chars, approx. 5 rows of text)
*6.	Question - Required - What is the event location (virtual, city, state, country, etc.) (Maximum response 255 chars, approx. 5 rows of text)
*7.	Question - Required - Date of Event: Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923
*8.	Question - Required - Why do you want RESOLVE to participate? (Maximum response 255 chars, approx. 5 rows of text)
*9.	Question - Required - Who is the audience? (Maximum response 255 chars, approx. 5 rows of text)
*10.	Question - Required - Expected number of attendees:
11.	Question - Not Required - Any other information we should know?
*12.	Question - Required - Will this event be open to the public? Please select response Yes No Don't Know
*13.	Question - Required - Will there be a registration fee for attendees? Please select response Yes No
*14.	Question - Required - Indicate specific topic area(s) for RESOLVE content: (Maximum response 255 chars, approx. 5 rows of text)
*15.	Question - Required - What is your Preferred Presentation Format? Please select response Keynote Address In-person presentation Virtual presentation Panel Moderation Panel Participant Something Different Length of Session/Talk
*16.	Question - Required - Length of Session/Talk:
*17.	Question - Required - Will talk include a Q&A? Please select response Yes No
*18.	Question - Required - Will this event be open to the press? Please select response Yes No
*19.	Question - Required - Who would you like to speak at your event? Please select response Betsy Campbell Barbara Collura Rebecca Flick Tracie Sullivan Simmy Bookal Don't Know
*20.	Question - Required - Will there be an honorarium for the RESOLVE speaker? Please select response Yes No Don't Know
*21.	Question - Required - If travel is required, are travel costs reimbursed? Please select response Yes No Don't Know
*22.	Question - Required - How did you hear about us? (Maximum response 255 chars, approx. 5 rows of text)
*23.	Question - Required - Has RESOLVE done a speaking engagement with your organization in the past? Please select response Yes No
*24.	Question - Required - What is your relationship to infertility? Please select response I/We have been diagnosed with infertility I am a Professional who serves the infertility community I/We have resolved and have completed building my family I/We have decided to live without children I am a friend or family member of someone with infertility. Other
25.	Question - Not Required - Any special requests or comments? (Maximum response 255 chars, approx. 5 rows of text)

Spam Control Text:   Please leave this field empty