Safety & Support Online Speaking Engagement Request Form (English)

Thank you for your affiliate, chapter, division, or partner organization’s willingness to be involved in the transformational efforts to improve the NFB's culture. The National Federation of the Blind has a zero tolerance policy towards abuse and sexual misconduct of any kind. This form is meant to request presentations to your membership from a Survivor Task Force member. We welcome the opportunity to have an open dialogue with you and encourage those attending the meeting to ask questions or make suggestions for the Survivor Task Force to incorporate in our work or share with other National Federation of the Blind programs.

To assist us in serving your needs and effectively scheduling available Survivor Task Force Members, we ask that you complete this form at least two weeks prior to an event. We will make every effort to honor requests received less than two weeks out from an event.

First Name *

Last Name *

Title *

Affiliate, Chapter, Division, or Partner Organization *

Email Address *

Phone Number *

Event Name/Theme *

Event Location *

Event Start Time *

Event End Time *

Duration of Task Force Presentation *

Start Time of Presentation *

Note: We may schedule a Survivor Task Force member to present to multiple groups on the same day.

End Time of Presentation *

Do you have a specific focus or concern within the Task Force’s mission or do you need a general presentation? *

Anticipated Number of Attendees *

Should the presentation be conversational or formal? *

Please describe your audience. *

Is there anything else we should know about your event or group? *