First Name
Last Name
Phone
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Email
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Country
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Website
What is your profession?
Your social media handles
Your speaker bio
What gift will you offer our community?
Three core points you would like to discuss in your interview
Why are you passionate about empowering women and girls?
Suggested interview questions or discussion points (optional)
Where can your gift be used?
Worldwide
Nationwide within my country
Other (please explain in your gift answer)
How many subscribers are on your email list?
Under 500
500 to 1,000
1,000 to 5,000
5,000 to 10,000
Over 10,000
Summit promotion commitment
Yes, I will share 2 social media posts and 2 short email blurbs with my network in the 4 weeks before the summit (provided by the club)
Interview availability commitment
Yes, I can book a 45 minute slot for a 30 minute recorded interview between 6 January and 10 February 2027 (Brisbane time, AEST)
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