Youth Advocacy and Leadership Night - February 2024

Youth must have a mental health diagnosis or disability and be between the ages of 14-18.

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* 1. Name of youth:

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* 2. Preferred name & pronouns:

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* 3. Birthdate:

Date:

Date

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* 4. Grade in school:

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* 5. Diagnosis/Disability:

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* 6. Address:

Address *

Address 2 *

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number *

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* 7. Preferred method of contact:

Email

Phone

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* 8. My adult's (emergency contact) name:

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* 9. My adult's address (if different than my own):

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 10. What has been your experience in school as a youth with mental health challenges?

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* 11. Do you have any public speaking skills?

Yes

No

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* 12. If not, are you interested in developing those skills?

Yes

No

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* 13. Are you willing to speak in public/with legislators about your diagnosis or disability?

Yes

No

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* 14. What changes would you like to see for youth who have mental health needs or who receive Special Education services (i.e, in schools, communities, families, health care, laws, among peers)?

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* 15. Do you need any accommodations? Please explain.

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* 16. Do you have any questions about participating in our Youth Advocacy night?

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* 17. Will you be able to attend our Day at the Capitol March 7th (a parent/guardian will need to attend with you and provide transportation)?

Yes

No