Médecins Sans Frontières Speaker/Event Request Form

Please take the time to fill in as many details as you can in the request form below. This will help us at Médecins Sans Frontières to respond to your request promptly.

In which country will your event be held? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Médecins Sans Frontières respects your right to protection of your personal information. All information collected on this request form will be used only to organise a speaker for your event and will be held in accordance with the Médecins Sans Frontières Privacy Policy available in full at www.msf.org.nz.

This is a Médecins Sans Frontières New Zealand Application. Please refer to the Médecins Sans Frontières New Zealand Privacy Policy for relevant information.

This form is through a 3^rd party website based in the USA. Please also read the Cognito Forms Privacy Policy before proceeding to disclose any personal data.

This is a Médecins Sans Frontières Australia Application. Please refer to the Médecins Sans Frontières Australia Privacy Policy for relevant information.

This form is through a 3^rd party website based in the USA. Please also read the Cognito Forms Privacy Policy before proceeding to disclose any personal data.

Do you intend to fundraise for Médecins Sans Frontières at this event? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you filled out Médecins Sans Frontières Community Fundraising Application? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Please note that fundraising for Médecins Sans Frontières New Zealand requires special approval. Fill out your email below to receive information about fundraising for Médecins Sans Frontières New Zealand before requesting a speaker/attendee at your event.

Please note that fundraising for Médecins Sans Frontières Australia requires special approval. Fill out your email below to receive information about fundraising for Médecins Sans Frontières Australia before requesting a speaker/attendee at your event.

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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ORGANISATION DETAILS

Organisation Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Street Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Street Address Line 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City/Suburb {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State/Province/Region {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Post Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please give us a brief description of your organisation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

EVENT DETAILS

Event Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Brief Description of Event {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If selected 'other' audience type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If selected 'other' event type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Estimated Number of Attendees {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

EVENT LOCATION

Has the event location been confirmed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Event Street Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Event Street Address Line 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City/Suburb {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State/Province/Region {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Post Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please proceed to the next page. MSF will be in contact soon to confirm the event location details.

EVENT DETAILS

SPEAKER/ATTENDEE REQUIREMENTS

You may select to have a speaker at your event, however, if you have an event that does not require a speaker you may simply request for someone to attend the event, ie. An MSF representative to attend a Career Expo.

Do you require a speaker? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Select the type of speaker you would prefer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Select the preferred session type for the speaker {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

List speaker topics - if speaker required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Have you confirmed the event date/s and times? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

MSF will be in contact soon to confirm the event dates and times.

Event Date - Attendance Required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Event Time - Attendance Required From {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Event Time - Attendance Required Until {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Time allocated for Speaker {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Speaker/Attendee Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Equipment Available {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other Equipment Available {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Resources Required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

EVENT ORGANISER CONTACT DETAILS

First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Position Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Work Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

OTHER DETAILS

Where did you hear about MSF? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please indicate any other event information you want to communicate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you have any event flyers or brochures to attach? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Notes {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

MSFA Strategic Outcome {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Médecins Sans Frontières Speaker/Event Request Form

ORGANISATION DETAILS

EVENT DETAILS

EVENT LOCATION

EVENT DETAILS

SPEAKER/ATTENDEE REQUIREMENTS

EVENT ORGANISER CONTACT DETAILS

OTHER DETAILS

Médecins Sans Frontières Speaker/Event Request Form

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Médecins Sans Frontières Speaker/Event Request Form

ORGANISATION DETAILS

EVENT DETAILS

EVENT LOCATION

EVENT DETAILS

SPEAKER/ATTENDEE REQUIREMENTS

EVENT ORGANISER CONTACT DETAILS

OTHER DETAILS