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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.
* 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
Name of Spouse/Partner:
Spouse/Partner Adopted: Yes No Birth Country:
Children M/F DOB Birth Country if Adopted Other Info

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.
I give Holt International (“Holt”) the right to release my name and contact information to the media. I further give to Holt the right to distribute, disseminate, publish (including internet): contact information, images, likenesses, pictures or photographs (“Rights”) for any lawful purpose.

    
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