Speaking Out Request Form
Name *
Your answer
Pronouns (he, she, they etc.)
Your answer
Phone Number *
Your answer
Email Address *
Your answer
School/Organization Name *
Your answer
Address (Street, City, Zip) *
Your answer
Date for Requested Panel *
MM
/
DD
/
YYYY
Date for Second Requested Panel (if necessary)
Only use this if you are requesting panels on 2 separate days
MM
/
DD
/
YYYY
Time of Panel *
Please add the beginning and end time for your panel
Your answer
Second panel time (if needed)
Please add the beginning and end time for your second panel if this request is for multiple class sessions
Your answer
Third panel time (if needed)
Please add the beginning and end time for your third panel if this request is for multiple class sessions
Your answer
Fourth panel time (if needed)
Please add the beginning and end time for your fourth panel if this request is for multiple class sessions
Your answer
Size of the Class *
Your answer
Median Age of Class *
Your answer
Class Subject (If Applicable)
Your answer
Location and Instructions to Find Classroom/Meeting Room *
Your answer
Accessibilty *
We have panelists with limited mobility or special access requirements. Does your building have ramps and elevators?
Your answer
Parking Information for Panelists *
Your answer
Why Are You Requesting a Panel? *
What context? What has happened, if anything?
Your answer
Any Special Request(s) for Panel Members?
Would it be most helpful if the panelists were of a certain age range, background, orientation, or gender identity? Would a bilingual member, person of faith, parent, or some other identity help your students or group to better relate to the experiences of the panelists?
Your answer
How Did You Hear About Speaking Out?
Your answer
Is There Anything You Wish to Add?
Your answer
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