Request To Become a Monthly Volunteer Youth Speaker
Member Speaker
Date *
MM
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DD
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YYYY
First name *
Middle name *
Last Name *
Date of birth *
Email *
Phone number *
Name of employer *
Employer phone number *
Emergency contact name: *
Emergency contact number *
Were you ever arrested as a juvenile:
Clear selection
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 *
Did you serve a prison sentence *
Total years in state custody *
Total years in federal custody *
Are you currently on any of the following *
Name of current probation/parole officer *
Phone number for probation/parole officer *
Prior gang affiliation *
Name of prior gang affiliation *
Purpose for participating in the Program: *
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: *
Do you believe a program such as Real Talk can make a difference and why: *
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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