Senate Committee Hearing Survivor Participation Form

Thank you for your interest in participating in virtual and/or in-person opportunities at the upcoming Senate Finance Committee Hearing. Please fill out the form below to provide us with some basic information and to indicate your level of interest in different activities.

Your input is invaluable in our efforts to ensure the safety and well-being of youth in residential treatment facilities. You will be receiving an email in the next couple of days from impact@1111media.co, please watch your emails!

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Full Name *
Email Address *
Phone Number
Zip Code *
Which facility did you attend? *
How old were you when you attended the facility? *
What years did you attend this facility? *

Would you be interested in recording a short video about your experience at the facility to be shared with Congress during the Committee Hearing to ensure we have survivor voices as a part of it? We will follow up with information on how to submit your video.

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Would you be willing to provide written testimony to the Senate Finance Committee about your experiences?

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Would you be interested in attending the Hearing in person? (You would be responsible for any travel or lodging costs) *
Is there anything else you would like us to know about your experience or how you would like to contribute? Please let us know!

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