SpeakUp! Event Registration

Please complete the form below to register for an upcoming SpeakUp! event:
Participant Info
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*
This email address must be the same email address used for your Zoom account. We use your email address for breakout room assignments, so it is important for each family member to use their own. If you do not have a Zoom account, click here to create one.
Phone*
Phone number will be used if additional support is needed during or after the event.
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: 2029
7th: 2028
8th: 2027
9th: 2026
10th: 2025
11th: 2024
12th: 2023
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)
Mental Health
- Depression
- Suicide
- Anxiety
- Stress
- Self esteem
- Loneliness
- Exclusion
- Peer relationships
- Abuse
- Treatment
- Substance abuse- drugs, alcohol, vapes, smoking
- Social media
Acceptance/Bullying
- Bullying is an important topic because...
- Verbal bullying
- Cyber bullying
- Acceptance comes in many different forms like...
- Appearance
- Don't judge a book by its cover...
- Teachers should respect students because...
- What is bullying?
- Name calling
- Including others
- Friend groups
Expectations
- Grades
- Social media
- Body image
- Parents
- Sports
- Teachers
- Peers
- Self harm
- Anxiety
- Addiction
- Need for approval
- Lack of growth
School Environment
- Dress code
- Drugs/vaping
- Safety/feeling safe
- Peer pressure
- Teacher expectations
- Reputations
- Language/offensive language/cursing
- Consequences
- Phones
Topics: 1st Choice*
Topics: 2nd Choice*
Topics: 3rd Choice*
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.*
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
- 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]
Email
This field is for validation purposes and should be left unchanged.

First name	Middle initial	Last name	This person is my

Participant Info

Breakout Session

Topics (click here to view topic talking points)

Mental Health

Acceptance/Bullying

Expectations

School Environment

Family Members Attending

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