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