EmailMe Form - Truth Out Loud Workshop Series Application

Name *

First Last

Email *

Phone Number *

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Gender Pronouns *

She/her/hers

He/him/his

They/them/their

Other

How did you hear about this workshop series? *

Age *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Workshop Series Dates & Description

The workshop series will be held in Baton Rouge on the following dates in 2020

Orientation: Thursday, January 9th from 5:30 PM to 7:30 PM

Workshop 1: Saturday, January 11th from 8:30 AM to 12:00 PM

Workshop 2: Saturday, January 18th from 8:30 AM to 12:00 PM

Workshop 3: Saturday, January 25th from 8:30 AM to 12:00 PM

Participants are required to attend the orientation and all three workshops in the series. Can you commit to attending the orientation and all of the workshops as scheduled? *

Yes

No

About You

Below we ask you to share about yourself and your interest in this workshop series.

Are you currently involved in a legal matter related to your assault? *

Yes

No

Why are you interested in participating in the Truth Out Loud Workshop Series? *

Speakers tell their stories primarily to educate communities about sexual violence. What do you want members of your community to know about sexual violence? What actions do you want people to take to prevent and/or react responsibly to sexual violence? *

It's common for people to have concerns about sharing their story publicly. What concerns do you have about how sharing your story might affect you? *

Are you currently or have you in the past year been involved with STAR in another way, including volunteering for another program or receiving STAR services? If so, please list what program(s) you are a part of, and/or what type of service(s) you have received. *

Have you received any type of counseling or therapy for the sexual violence or abuse you've experienced? *

Yes

No

If so, please describe the type of therapy (individual, group, etc.) and length of time you received services. *

Do you have any accommodation needs to be able to fully participate in the workshop series? (e.g. interpreters or large print materials) *

Please write any additional comments or questions here.