Survivor Speaker's Bureau Interest Form

Survivor Speaker's Bureau Interest Form
PURPOSE

The purpose of the Survivor Speaker's Bureau (SSB) is to increase awareness about sexual assault (SA) and intimate partner violence (IPV) through public speaking and education, and to inspire social change. Speaker's Bureau members will speak to various groups and organiztions, helping to counter myths and misperceptions about intimate partner violence and sexual assault that are prevalent within the community.
SHARE A STORY
- Are you a survivor of sexual assault or intimate partner violence who wants to use public speaking as a tool for social change?
- Explore how to use your story to help change perceptions about sexual assault and intimate partner violence. Learn how to counter myths and misconceptions, create dialogue and field questions.
- For more information you can call 248-334-1284, ext. 350.
INTERESTED TO LEARN MORE?

If you are interested in finding out more about the program and how you may be able to participate, please complete the following questionnaire.

The information in this form is encrypted, and will not be used or distributed in any way outside HAVEN without your express permission.
Your name*

First NameLast Name
Email
example@example.com
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
In what city do you live?
What is the best way to contact you? (Select multiple)

EmailPhone callText messageOther
If "Other," please explain
The position will require in-person involvement. Will you be able to make necessary travel arrangements?*

YesYes, but I may need some assistanceNo
Please explain
Have you experienced any of the following?*

Sexual AssaultIntimate Partner ViolenceStrangulationHuman TraffickingUnsure
Tell us about yourself. What unique qualities would you bring HAVEN'S Speakers' Bureau? Why would you like to join the Survivor Speaker's Bureau?*
Please share your story.*
If you encountered a situation where an individual was disruptive, how would you handle it?
What steps would you take to ensure clients feel empowered to make choices regarding program participation and what kind of support they need?
DUTIES OF SPEAKERS
Below is a list of duties of a speaker. Please select all that you would feel comfortable taking part in. You don't have to participate in all elements to be considered. So, please let us know what you might be interested in..

Engaging in outreach to victims/survivors of Sexual Assault or Intimate Partner ViolenceEducating individuals on their inherent rights within our system and the grievance process available to themProviding education on an array of additional topics that in which victims/survivors indicate a desireEmpowering individuals to share their voice to promote system changeGathering input about improvements needed in the systemCapturing program data from educational sessions, one-on-one support and any other services provided through the programSharing your story via social mediaSharing your story via videoSharing your story via written contentOther
Please expand on any of the areas selected above.
As the program evolves, the SSB may change. Are you open to remaining flexible as roles may change?

No
Please provide any scheduling information that describes your availability and willingness to participate in meetings, activities and events.*
Is there anything more you'd like to know about becoming part of the Survivor Speakers Bureau?
Should be Empty:

Survivor Speaker's Bureau Interest Form

DUTIES OF SPEAKERS