Neuroinclusion Hub Speaker Gallery Sign Up

See the Speaker Gallery here for details, examples & inspiration: https://www.neuroinclusionhub.com/speaker-services

If you need help filling out this survey or have accessibility concerns, please reach out to rebecca-alley@neuroinclusionhub.com.

Please note: The speaker gallery is open to self-diagnosed and clinically diagnosed individuals who have any condition included in the neurodiversity paradigm. 

Please note you will need to consent to a background check to be part of Speaker Gallery.
Dear Neuroinclusion Hub Community,

At Neuroinclusion Hub, we are committed to fostering a safe and inclusive environment for everyone involved. As part of our ongoing efforts to ensure a secure space, we conduct background checks on our Speaker Gallery.

We understand that financial circumstances vary, and we believe in the principle of inclusivity. To sustain our mission, we're introducing a sliding scale option for covering the cost of background checks ($50 for USA applicants and $150 for international applicants). If you find yourself in a position to contribute, we invite you to participate in supporting the financial aspect of your background check.

Your voluntary contribution, no matter the amount, will directly contribute to maintaining the integrity and safety of our community. It's a small way to collectively invest in the shared responsibility we have for each other's well-being.

Thank you for being an integral part of the Neuroinclusion Hub community, and for helping us create an environment where everyone feels secure and valued.

Warm regards,
Neuroinclusion Hub

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* 1. Optional Background Check Contribution (USD)

1 - $1 USD 300 - $300 USD
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i We adjusted the number you entered based on the slider’s scale.
You’ll enter payment info after the survey.

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* 2. Where are you located (for background check purposes)?

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* 3. Do you consent to a basic background check by Mind Your Business, Inc.? Please Note: This is required to participate.

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* 4. Do you identify as neurodivergent?

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* 5. First Name (as you'd like listed in the gallery)

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* 6. Last Name (as you'd like listed in the gallery)

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* 7. (Optional) Pronouns (as you'd like listed in the gallery)

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* 8. Email

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* 9. LinkedIn URL

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* 10. Personal Website URL

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* 11. (Choose all that apply) What Services are You Open to Offer?

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* 12. Are You Open to In-Person / Virtual?

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* 13. What topics do you prefer to cover?

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* 14. Are you open to free events?

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* 15. If open to in-person, what Geographic Locations are you open to doing In-Person events (No Travel Fees)?

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* 16. If open to in-person, what Geographic Locations are you open to doing In-Person events (With Travel Fees)?

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* 17. (OPTIONAL) What is your speaker fee?

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* 18. Do you want your speaker fee listed publicly?

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* 19. (Optional) Do you need accommodations at speaking events?

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* 20. (Optional) What accommodations are needed for virtual events?

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* 21. (Optional) What accommodations are needed for in-person events?

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* 22. Do you want your accommodations listed publicly?

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* 23. Please include your bio here as you'd like shown on the gallery

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* 24. Please upload a headshot or picture as you'd like shown on the gallery

PNG, JPG, JPEG file types only.
Choose File

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* 25. Please write alt text that you're comfortable including with your gallery picture.

Please include a description of what you look like and what you are wearing in the picture.

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