SpeakUp! Event Registration

Email
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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)
Body Image/Body Changes
- Name-calling (fat, bony, big back)
- Passive-aggressive comments
- Body dysmorphia
- Eating disorders/anorexia
- Making fun of eating disorders
- Wanting to be a different size/someone else
- Comparing to others
- Not wanting to be friends because of their weight
- Not having access to healthy food
- Risking health to achieve a weight goal
- Dieting/weighing yourself constantly
- Puberty
- Self harm
- Wanting to gain weight
Home Environment
- Abuse/neglect
- Impulse
- Lack of resources/lack of money
- Feeling trapped, alone/Feeling stuck
- Sanitation
- Chores/forced responsibility
- Hoarding
- Parental understanding/validation/expectations
- Grief
- Parental immaturity/parent drinking
- Comparison
- Favoritism
- Relatives/sibling relationships
- Having to provide things for yourself
- Making fun of someone's beliefs
- Raising siblings and yourself
- Making fun of someone who has special needs
Mental Health
- Drugs
- Suicide/self harm
- Feeling unloveable
- Stress
- Depression
- Bullying
- Home problems
- Parents arguing/divorce
- Drama
- Social media
- Thinking you're not good enough
- Grades dropping
- Friendship/relationship breakups
- Changing yourself for others' approval
- Vulnerable
- On edge
- Having mental/physical disabilities
Social Media
- Cyberbullying/verbal abuse/hate speech
- Blackmailing
- Catfishing/stalking
- Oversharing/sympathy fishing
- Comparison
- Addiction
- Drama/gossiping/"Tea" pages
- Bad trends
- Video Games
- Peak rage bait
- You're exposed to stuff at a young age
- Friendship/relationship fallouts
- Gaslighting
- Posting embarrassing pictures/videos
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/Body Changes

Home Environment

Mental Health

Social Media

Family Members Attending

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