Request To Become a Monthly Volunteer Youth Speaker
Member Speaker
Date *
MM
/
DD
/
YYYY
First name *
Your answer
Middle name *
Your answer
Last Name *
Your answer
Email *
Your answer
Phone number *
Your answer
Name of employer *
Your answer
Employer phone number *
Your answer
Emergency contact name: *
Your answer
Emergency contact number *
Your answer
Were you ever arrested as a juvenile:
Were you ever on juvenile probation/parole and if so which one. *
Have you ever been arrested as an adult *
Are you a convicted felon *
ADULT CONVICTIONS/OFFENSE *
Your answer
Did you serve a prison sentence *
Total years in state custody *
Your answer
Total years in federal custody *
Your answer
Are you currently on any of the following *
Name of current probation/parole officer *
Your answer
Phone number for probation/parole officer *
Your answer
Prior gang affiliation *
Name of prior gang affiliation *
Your answer
Purpose for participating in the Program: *
Your answer
As a juvenile, what do you believe was missing in your life at the time that could have made a difference in the choices you made throughout your adult life: *
Your answer
Do you believe a program such as Real Talk can make a difference and why: *
Your answer
Would you be willing to participate in the Program following the completion of your supervision (if you are currently on supervision) *
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