SpeakUp! Event Registration

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Please complete the form below to register for an upcoming SpeakUp! event:
Participant Info
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Speakup Staff
You can select from contacts that have been previously assigned to a Facilitator, Staff, or Volunteer Group in CiviCRM
Choose Prior
Select the SpeakUp! Event you're registering for:*
Name*
.
First Last
Address*
Street Address City State ZIP Code
Email*
Phone*
Phone number will be used if additional support is needed during or after the event.
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Which gender pronouns do you identify with?*
Are you on the Student Leadership Team for this event?*
Participant Type*
School Staff Type*
Which school are you associated with?*
Student's grade*
Student's High School Graduation Year*
Grade to Graduation Year Chart
6th: 2032
7th: 2031
8th: 2030
9th: 2029
10th: 2028
11th: 2027
12th: 2026
Breakout Session
You will be participating in ONE Breakout Session. Please Rank your top Breakout choices in order of preference: (1-3)
Topics (click here to view topic talking points)
Self-Esteem
- Appearance
- Body-shaming
- Beauty Standards
- Manipulation
- Judging people
- Lack of Confidence & self-worth
- Disliking your own appearance
- Acne
- Skin disorders/conditions
- Not Feeling pretty
- Body dysmorphia
- Lack of Self-satisfaction
- Overthinking
Racism
- Racial profiling
- What’s wrong with having physical differences ?
- Equality
- Why does skin-color matter?
- Calling people offensive names
- Stereotypes
- Different treatment because of background/race
- People making fun of your accent and where you from
- Superiority because of race
- Why is one race/skin color better than the other ?
- Identify
- Racial Slurs
- Why am I treated differently?
- Religious/Cultural Differences
- Feeling isolated
- Ism/Phobia (Islamophobia, Xenophobia, etc.)
Mental Health/Depression
- Depression
- Self-hate/Self-harm
- Venting (talking about issues)
- Mental Health disorders (ADHD, Bipolar, OCD, PTSD, etc.)
- Not having time for yourself
- Disability (Autism, ADHD, etc.)
- Peer pressure
- Bullying
- Expectations
- Anger issues
- Adults not realizing youth have mental health issues
- Child abuse
- Eating disorders
Anxiety/Stress
- Academic stress
- School & Work Balance
- Not knowing what’s next
- Panic attacks
- Past Traumas
- Sports/Extracurricular Activities
- Fake friends
- Peer pressure/trying to fit in
- Being afraid to speak up
- Smoking or Bad Habits
- Self-harm/Self-hate
- Family Issues/Relationship Issues
- Keeping up with expectations
- Trouble concentrating/Overstimulation
Topics: 1st Choice*
Topics: 2nd Choice*
Topics: 3rd Choice*
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Topic/Room Selection
Note: Please be sure you have selected 3 different Topics.
*We will do our best to give you your first choice topic, but it is not a guarantee.*
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Contact Preference
- Click here to opt-out of Speakup! emails which include valuable resources, Parenting Adult Coffee Invitations, School Adult Discussion Invitations, Youth Mental Health First Aid Training Opportunities and much more.
Will other family members be attending this SpeakUp! event?
Family Members Attending
NOTE:THIS DOES NOT REGISTER THAT FAMILY MEMBER. All Participants must register separately. Listing family members below ensures you will not be in the same breakout with those listed.
Attending Family*
First name Middle initial Last name This person is my
e.g. Parent's name is John Smith and email is [email protected], and student's name is also John Smith with an email address of [email protected]
- My name and email address are the same as my child or parent.
e.g. Parent's name is John Smith and email is [email protected], and student's name is also John Smith with an email address of [email protected]

First name	Middle initial	Last name	This person is my

Participant Info

Breakout Session

Topics (click here to view topic talking points)

Self-Esteem

Racism

Mental Health/Depression

Anxiety/Stress

Family Members Attending

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