SpeakUp! Event Registration

Email
This field is for validation purposes and should be left unchanged.
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)
Body Image
- Bathing suits/Tight clothes/fitted clothes/trends
- Comparison/other people's figures
- Comments
- Social media- influencers, filters
- Looks: appearance/face features/make-up/hair type
- Height & weight standards/bloating
- Skin color
- Skin conditions
- Eating disorders
- Confidence/individuality
- Insecurities
- Ethnicity
- Cultural outfits
- Dysmorphia
Comparison
- Family
- Friends/classmates
- Sports
- Looks/body image
- Social media
- Style
- School: grades (knowledge)/work ethic
- Money
- Popularity
- Relationships
- Emotions
- Self-esteem/confidence
- Your background
- Personality/characteristics
Mental Health
- School (grades, sports)
- Insecurities
- Social media
- Anxiety
- Friends: drama/popularity/peer pressure
- Family
- Isolation/being left out
- Expectations: failure, comparison, competition
- Opening up/expressing emotions/jealousy
- Confidence/self-esteem
- Addictions
- Fear of the future
- Relationships: secrets/trust issues
- Body Image
- Disorders (ADHD)
- Trauma
Stress & Overthinking
- Speaking freely/emotions
- Homework/grades/tests
- Relationships: fake friends, drama, crushes
- Old conversations/past experiences
- Body image
- Other people's opinions, perceptions, judgement
- Pressure
- Overhearing things
- Body language/tone of voice
- Food
- Confrontation
- Anxiety/stress
- Second-guessing/choices made
- Yours/others' actions/reactions
- Your future/others' future
- Social media
- Performance- sports, school, etc
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)

Body Image

Comparison

Mental Health

Stress & Overthinking

Family Members Attending

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