Name We need your name.

Street Address

City State ZIP

Phone We need your phone number to contact you.Please use format: (608) 123-4567.

Email Please type a valid email address.

Birthdate A value is required.Please use format: mm/dd/yy

Please Select Your Preferred Way to be Contacted (please check one):

Phone
Email
Other Please make a selection.

Please Select Your Preferred Time of Day to be Contacted (feel free to check more than one):

Morning
Afternoon
Evening

May we provide your contact info to the person requesting an Expert Youth Speaker so they can get in touch with you directly (please check one)? If not, we will contact you with the details.

Yes
No

Do you charge a speaker fee? If so, how much?

Yes
No

Have you spoken or presented to groups before?

Yes
No

If so, please provide the Names, Locations, and Audience (class, youth, teachers, parents, mixed) below:

Presentation 1

Presentation 2

Presentation 3

Please provide the Names, Phone Numbers, and Email Addresses of 1 to 3 people who have heard you speak before:

Contact 1

Contact 2

Contact 3

Please provide a brief paragraph about yourself (for example, hobbies, if you have or had a job, go to high school or college, where you live, etc.):

About me:

Please check the following topics you are comfortable talking about, or add your own:

Transitioning from high school to work or college
Attending a technical college or university (receiving disability services)
Disclosing your disability to an employer
Reasonable accommodations on the job
Being a good self-advocate
Participating in or leading your own IEP
Meaningfully involving youth in policy decisions, committees, etc.
Managing your own health care
Personal experience with a youth activity (i.e. YLF, Gathering of Youth, KASA)
Becoming a youth leader
Moving out
Other (Please specify)

May we include a picture of you, your bio, and your e-mail address on this website so people looking for speakers can find you more easily?

Yes
No