WD2023 Speaker Suggestion Form Speaker Information Question Title * 1. Are you submitting this form on behalf someone else? Yes No Question Title * 2. If yes, what is your name? Question Title * 3. If yes, what is your email address? Question Title * 4. Speaker's full name Question Title * 5. Speaker's contact information Email Address Question Title * 6. Speaker's age Under 18 18-29 30-39 40-49 50-59 60-69 70-79 80+ Question Title * 7. Speaker's gender Agender Intersex Cisgender Woman Transgender Woman Cisgender Man Transgender Man Non-Binary/ Gender nonconforming/genderqueer Prefer not to say Other (please specify) Question Title * 8. Preferred pronouns She/her He/his They/them Ze/hir No preference Prefer not to say Other (please specify) Question Title * 9. Speaker's country of issuing passport Question Title * 10. Speaker's country of residence Question Title * 11. Does the speaker identify with any of the following? Ethnic, racial or religious group Indigenous person Informalized worker Intersex Lesbian, Gay, Bisexual, Queer, Questioning, Asexual + Living in a rural area Migrant or in migration Person with a disability/disabled person Person living in a humanitarian or crisis setting Refugee or displaced person Transgender Unhoused Undocumented and/or stateless Other (please specify) Question Title * 12. Speaker's organization, if applicable Question Title * 13. Type of organization Academia Business/ Private sector Community-Based Organization Faith-Based Organization Government (national, regional, local) Health facility International Non-Governmental Organization (iNGO) Media National Non-Governmental Organization (NGO) School University UN Agency or multilateral organization Other (please specify) Question Title * 14. Speaker's job title Question Title * 15. Speaker's area of expertise Accountability Adolescents Care Economy/Unpaid Care Arts/Creative Expression Climate Action Crisis & Humanitarian Assistance Communicable diseases Digital Rights COVID-19 Economic Justice & Rights Education Environment Disability Rights Gender-Based Violence & Harmful Practices Gender Equality Health Systems/Universal Health Coverage Gender Financing Human Rights Faith & Religion Health Workforce Maternal, Newborn, Child Health Migration Infrastructure, including Water & Sanitation Mental Health Noncommunicable Diseases Labor Rights Nutrition/ Food Security Land Rights Sexual & Reproductive Health & Rights/ Bodily Autonomy LGBTQIA+ Rights Racial Justice Social Protection Sex Worker Rights Women in Politics and Decision-making Social Justice Youth Engagement/ Leadership Other (please specify) Question Title * 16. Speaker's primary area of work Academia Advocacy Arts Communications/Public Relations Community Organizing Donor Fundraising Government/Policy Health Provider Humanitarian Assistance Media Programming (design, implementation) Research Social Marketing Other (please specify) Question Title * 17. What topic(s) could they speak to during the Conference? Accountability Adolescents Care Economy/Unpaid Care Arts/Creative Expression Climate Action Crisis & Humanitarian Assistance Communicable diseases Digital Rights COVID-19 Economic Justice & Rights Education Environment Disability Rights Gender-Based Violence & Harmful Practices Gender Equality Health Systems/Universal Health Coverage Gender Financing Human Rights Faith & Religion Health Workforce Maternal, Newborn, Child Health Migration Infrastructure, including Water & Sanitation Mental Health Noncommunicable Diseases Labor Rights Nutrition/ Food Security Land Rights Sexual & Reproductive Health & Rights/ Bodily Autonomy LGBTQIA+ Rights Racial Justice Social Protection Sex Worker Rights Women in Politics and Decision-making Social Justice Youth Engagement/ Leadership Other (please specify) Question Title * 18. Speaker bio (max. 100 words) Question Title * 19. Links to Speaker’s website and/or social media accounts, if applicable LinkedIn Twitter Instagram Other Question Title * 20. I agree Women Deliver may share my contact information with Women Deliver Conference organizers and/or partners looking to identify speakers for their programming. Yes No Done
