Speaker Proposal Form

The First International Birth Tear Summit will be held February 8, 2021. This will be a virtual event organized by Laura Fry, Founder of Life After 4th Degree Tears and the 4th Degree Tear Support Group on Facebook.

We are looking for a combination of 20-45 minute professional presentations and 5-15 minute patient stories. The target audience will be parents with severe tears and a diversity of professionals who work with them.

The presentations will be pre-recorded to avoid event glitches.

The deadline to complete the speaker proposal form is January 3, 2021. After presenters have been selected, the deadline to submit recordings will be February 1, 2021. Registration for this event will begin January 4, 2021.

Speaker Information

Name(required)

Email(required)

Phone Number(required)

Address(required)

Organization Name

Speaker Role, select one:

Parent with Severe Tear Professional who works with severe tears Both a parent with severe tear and a professional who works with severe tears Partner of someone with a severe tear

FOR PROFESSIONALS: Professional Title (We are looking for one speaker from each of these roles – OBGYN, urogynecologist, colorectal surgeon, midwife, physical therapist, mental health therapist, nurse, etc):

Presentation Title:

Presentation Description:

FOR PARENTS: Brief Story (We are looking to include a variety of experiences including fistulas, missed tears, incontinence, temporary or permanent colostomy bags, birth after a severe tear, positive stories, LGBTQ+, people of color, international stories, partner's perspective, etc.):

What is the one main thing other parents can take from your story:

What is the one main thing professionals can take from your story:

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