Youth Speak Out Form
Do you want to share your story or experiences related to sexual health? Fill out this form to be contacted when opportunities arise, such as panels or events where youth voices need to be heard!
Name (this does not need to be your legal name):
Age (must be 21 and under):
(optional question) What is your race/ethnicity? We ask this to ensure that voices of people of color are represented.
(optional question) What is your sexual orientation and gender identity? We ask this to ensure that voices of all sexual orientations and gender identities are represented.
Location (city or general area. If your location changes throughout the week or month, please feel free to leave more detailed response below):
Do you have transportation?
If you have a disability or any additional needs and require assistance in order to fully participate, please provide this information below, so we can accommodate.
How far are you willing to travel to share your story/experience (anywhere from 5min to across the state)?
Do you have a parent who would be willing to speak about their experience being a parent of a young person and topics related to sexual health?
Best way to contact (where you feel comfortable with us leaving a message if you are unavailable):
What areas of sexual health are you interested in speaking about- select all that apply:
Sexual Health Services
Additional comments or questions:
By submitting this form you consent to being contacted about speaking opportunities. We try to proivde stipends for speaking engagements, as well as mileage reimbursement, if possible. Please contact
if you have any questions or concerns. Thank you!
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This form was created inside of Michigan Organization on Adolescent Sexual Health (MOASH).
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