Speakers Bureau Application

Thank you for your interest in participating in Voices, the National Coalition Against Domestic Violence (NCADV) Speakers Bureau! Please fill out this application as completely as possible. Your voice will help educate and inform others about issues related to domestic violence. If you have any questions, please email Robin Brock at voices@ncadv.org or call 303.839.1852 x106. Please note that not all applicants will be matched to those requesting speakers due to sheer volume as well as other factors, however your information will remain in our database for future requests.

Country*
State / Province*
Address*
City*
*
*
*
*
*
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Email*
Confirm Email*
Phone
Have you assessed your safety regarding public speaking? Do you feel safe presenting in a public setting? Please explain.*
Are you comfortable with any audience size? If not, please specify.
Ethnicity
  • White or Caucasian
  • Black or African American
  • American Indian or Alaska Native
  • Asian or Middle Eastern
  • Native Hawaiian or Other Pacific Islander
  • Hispanic or Latino
  • Other
With which gender do you identify?
What language(s) do you speak fluently?*
Which branch of the military?
Are you differently-abled or disabled? Please explain.
Do you require special accommodations? Please explain.
Occupation
Area(s) of Expertise*
  • Married Partner Violence
  • Dating Partner Violence
  • Weapons Involved
  • Teen Involved Violence
  • Protection Order Involved
  • Child(ren) Involved
  • Substance Abuse
  • Stalking Involved
  • Sexual Abuse
  • Reproductive Coercion/Manipulation
  • Professional Athlete Involved
  • Workplace Involved Violence
  • Men as Victims
  • Women as Abusers
  • LGBTQ
  • Law Enforcement Involved Perpetrator
  • Immigrant
  • Guns Involved
  • Financial Abuse
  • Custody
  • Childhood Domestic Violence
  • Mental Health/Illness
  • Emotional Abuse
  • Military Perpetrator
  • Elder Abuse
  • Reproductive Coercion
  • Victim of Human Trafficking
  • Spiritual/Religious Abuse
  • Animal Abuse
  • Other
If Other, Please explain
Please provide a brief summary or topic of your speech as it relates to domestic violence. (500 words)*
Do you have a preferred audience? (For example, other victims & survivors, businesses, advocates, media, government, etc.)*
Do you have a website or social media account you'd like us to know about?*
Please list 3 previous speaking engagements. Include the type of event and topic.

Please indicate your availability. Select as many as applicable.

Weekdays*
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
Weeknights*
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
Weekends*
  • Saturday
  • Sunday
How far are you willing to travel?*
  • < 20 miles
  • 20-100 miles
  • 100-250 miles
  • 250-500 miles
  • 500-1000 miles
  • Nationally
Professional reference 1 (Name, Email Address, Phone, Relationship, Years Known)*
Professional reference 2 (Name, Email Address, Phone, Relationship, Years Known.)*
How did you hear about us?
If you do charge for speaking, how much?
Notes

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