Addiction Experience Speakers BureauSPEAKER REGISTRATION Survey

Thank you for your willingness to volunteer to speak to students about your addiction experiences. We appreciate your interest in helping them understand the effects of substance use & abuse on their lives.

While every aspect of the effects of addictions is important for students to know, we especially would like them to understand how addictions can affect their career opportunities and financial futures.

Please complete the information below, so we will be able let schools know you are willing to help.

1.FIRST Name(Required.)

2.LAST Name(Required.)

3.Full or abbreviated name you prefer to use publicly.(Required.)

4.Use my abbreviated name
(check all that apply)(Required.)

When publicizing to Schools & Youth Organizations

When in person, speaking to a group

N/A (you may use my full name)

5.Primary E-mail
[Please be accurate. This will be the primary mode of communication about the program.]
(Required.)

6.Additional E-mail
[Please be accurate. This will be the primary mode of communication about the program.]

7.Work Phone, with area code(Required.)

8.Cell Phone, with area code(Required.)

9.Home Phone, with area code

10.Business or Organization(Required.)

11.City(Required.)

12.State(Required.)

13.Your Position / Title(Required.)

The Addiction Experience Speakers Bureau will be made available to schools and other youth organizations to call on the volunteer speakers to come speak to their students.

Speaking opportunities may be for a small group or a classroom or a large auditorium presentation.

You are free to accept or decline any invitation according to your schedule &/or comfort level.

This opportunity is completely voluntary and any agreements are between you and the school(s) or organization(s) who may contact you.

14.I am willing to speak to:
(check all that apply)(Required.)

Small Groups

Classrooms (up to ~30 people)

Large Groups / Auditorium

Other

If "Other" please explain

15.Will you be telling your addiction story or someone else's?
(check all that apply)(Required.)

My Story

Someone I Know

If "Someone You Know" or "Both" please explain below, what is your relationship to the other person(s):

NOTE: If you are telling someone else's story, it is your responsibility to get their permission, where appropriate, before telling their story.

16.Please explain briefly why you are interested in volunteering for the Addiction Experience Speakers Bureau:(Required.)

17.Is there anything else you would like for us to know about your participation in this opportunity?

Current Progress,

0 of 17 answered