Speaker Request Form Name of Speaking Event* * Name of contact person* * First Name Last Name Phone Number * (###) ### #### Email * Speaking Event Specifics Event Location* * Is event date fixed or tentative?* * Event Date Event Time* * Duration of Speaking Time * Are there other speakers? If so, who?* * Number of attendees expected* * Honorarium (please write a specific U.S. dollar amount)* * The honorarium check should be made out to Health Justice MD Will honorarium be given in advance?* * Yes No Would you like to advance purchase a copy of Undue Burden for each attendee? Special arrangements needed Thank you! I equip advocate-minded individuals to effectively speak about abortion, organize around abortion and intersecting issues, and advance policies to improve access to care.
