Holt Adult Adoptee Speaker's Bureau Profile & Authorization Form

Do not enter anything in this field!

* 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:
I have submitted an electronic photo: Yes No
*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.