Speaker Profile
Questionnaire
We need your help in doing the best possible job of scheduling
speakers. Any information you provide us is confidential and will be
used for scheduling purposes only ... to help provide contrast and fill
special requests. Please feel free to include any additional
information you think might be useful and don’t hesitate to take more
space to answer any question. All answers are optional.
Return your completed questionnaire to Billy DeFrank Speakers
Co-ordinator, Chris Merryman
Thank you very much for being a part of Billy DeFrank Speakers.
Name
__________________________________________________________
Date ____________________
Where do you work?
____________________________________________
City ____________________
Is it ok to call you at work ( ) Yes ( ) No ... If
yes, work phone # _________________________________
What is your current profession?
_____________________________________________________________
Have you had other kinds of jobs in the past
___________________________________________________
__________________________________________________________________________________________
What is your educational background?
_______________________________________________________
__________________________________________________________________________________________
Your birthdate? ____________________________ Where did you grow
up _________________________
What was your family situation? (# of siblings, etc.)
____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Cultural background?
_______________________________________________________________________
Other languages spoken?
____________________________________________________________________
Socioeconomic background?
________________________________________________________________
Religious background?
______________________________________________________________________
What were you like in high school
___________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How long have you been out to yourself?
____________________________________________________
Are you out to your family?
________________________________________________________________
Where would you place yourself on the Kinsey scale?
(heterosexual) < 0
1 2 3
4 5 6
> (homosexual)
How do you identify yourself? ( ) gay man
( ) lesbian ( ) bisexual
( ) transgender
(No matter how you may view labels, we really need this for scheduling
purposes.)
Are you currently in a relationship? ( ) Yes
( ) No With a
( ) man or ( ) woman?
For how long?
____________________________________________________________________________
Have you been married or had a significant relationship with someone of
the opposite sex?
( ) Yes ( ) No
With someone of the same sex? ( ) Yes ( )
No
Do you have children? ____ How many _____ What are their ages?
____________________________
What’s your current living situation?
________________________________________________________
__________________________________________________________________________________________
Are you active in any other organizations?
____________________________________________________
__________________________________________________________________________________________
Tell us something about your hobbies and other interests :
______________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
next subject: Speaker
Certification Guidelines
back to table
of contents