Holt Adult Adoptee Speaker's Bureau Profile & Authorization Form Holt International would like to invite you to become a member of Holt's Adult Adoptee Speaker's Bureau. Holt is often contacted by different entities when expert opinion is needed around adoption. Holt would like to provide these entities with individuals who can provide a perspective. These individuals may be offering their experience and expertise to perspective adoptive parents, media, legislative bodies and at conferences.

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* required fields
*Last Name:		*First Name:
*Street:		*City:
*State:		*Zip:
*Phone:		*Mobile:
*Email:		*Age:
*DOB:		*Occupation:
*Birth Country:		Birth Name:
Adoption Agency:		Year Adopted:
Age When Adopted:
Have You Visited Your Birth Country: Yes No		What Year(s):
Family Information

Adopted Parent’s Names:
Siblings	M/F	DOB	Birth Country if Adopted	Other Info
	Male Female
	Male Female
	Male Female
	Male Female
Name of Spouse/Partner:
Spouse/Partner Adopted: Yes No			Birth Country:
Children	M/F	DOB	Birth Country if Adopted	Other Info
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
Check Areas of Interest:

General Adoption Experience	Race & Identity	Birth Search
Birth Country Travel	Advocacy	Other:
Willing to Speak To:
Reporters	Researchers	Government Officials
Picnics/Events	Adopted Youth	Adoptive parents
Conferences	Teleconference
*Briefly describe your adoption experience:
*Send us your photo(less 3 MB):
*Please check the checkbox below before submitting.
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