Thank you for your interest in having a speaker share their story with your organisation. All of the information within this form is required and will assist in the selection of the most appropriate speaker and will become part of the brief for a speaker. We request four weeks notice. This form is also available online via SurveyMonkey: https://www.surveymonkey.com/r/request_a_speaker Date of request submission: YOUR CONTACT DETAILS Business/Organisation Name: Business Postal Address: Street Address (if different from Postal Address): Contact Name: Direct Phone Number: Mobile: Email: BASIC EVENT DETAILS Event Title: Day and Date of Event: Time of Event: Venue Name: Venue Street Address: Suicide Prevention Australia P: 0292621130 Page 1
Suicide Prevention Lived Experience Speakers have a lived experience of suicide. Suicide Prevention Australia defines a lived experience of suicide as having experienced suicidal thoughts, survived a suicide attempt, cared for someone who has attempted suicide, been bereaved by suicide, or having been touched by suicide in another way. Our Speakers help to: Improve the community s understanding of suicide Correct myths and stereotypes about suicide Reduce fear, shame and stigma Encourage people to seek support if they are experiencing suicidal thoughts or if they are concerned about someone Why does your organisation want a Lived Experience Speaker for your event? What would be the benefits to the audience? ADDITIONAL EVENT DETAILS Is the venue served by Public Bus Train Tram Ferry None Transport? (select all that apply): Will the Speaker have access to free parking? Describe any special conditions/requirements if appropriate: Will beverages/light snacks/meal be offered to the Speaker? Is the venue disabled friendly? Suicide Prevention Australia P: 0292621130 Page 2
DETAILS RELATING TO THE SPEAKING ENGAGEMENT On-the-day contact person for the Speaker: Contact person s mobile phone number: Is the Speaker needed for the duration of the event? Will the Speaker have an opportunity to mingle with the audience members before speaking? What time should the Speaker arrive? Will the event have multiple speakers? If yes, please describe how many other speakers and what their topics will be. Provide speakers names if they are available. Approximate number of minutes you have allotted for the Speaker (including Q&A time, for example, 20 minutes to speak + 5 minutes Q&A = 25 minutes total) Tell us about the audience (including age range, gender mix, special interests). Are there any cultural protocols that the speaker should know about in advance? Expected size of audience (approximate minimum and maximum numbers) AUDIO-VISUAL RESOURCES What AV resources are available? Microphone Podium/Lectern Laptop Data Projector Digital Pointer Suicide Prevention Australia P: 0292621130 Page 3
Our Speakers share their story using evidence-based safe messaging to reduce the likelihood of causing distress to audience members. However, there can still be persons who may experience unexpected emotions, feelings and memories from past events. Please describe how your organisation will provide for the emotional safety of audience members. Please provide any additional information you feel will be helpful. Suicide Prevention Australia P: 0292621130 Page 4
FEES APPLICABLE TO THIS BOOKING The Suicide Prevention Lived Experience Speakers Bureau provides organisations with professionally trained speaker who will motivate and inspire audiences to actively support suicide prevention. All speaking engagements are based on the trained speaker delivering a talk lasting between 15 25 minutes. Member of Suicide Prevention Australia Government Not-for-Profit organisations (nonmembers of SPA) Corporate and for-profit organisations Members are able to request a speaker two (2) times per financial year at no charge. $100 fee applies for additional engagements. $250 (+ GST) $100 (+ GST) $500 (+GST) Notes: 1. When travel to and from the venue is significant, accommodation, food and miscellaneous expenses are the host organisation s responsibility and subject to negotiation. 2. The Suicide Prevention Lived Experience Speakers Bureau is dedicated to addressing the widest audience possible and fees are negotiable where financial constraints would limit your organisations access to this service. What will happen once you have submitted this form? You will receive confirmation of receipt within 4 business days. We will make every attempt to secure a speaker for your event, depending on availability of speakers and event location. If you have any questions email livedexp@suicidepreventionaust.org or call 02 9262 1130. Suicide Prevention Australia P: 0292621130 Page 5