Community Partner & Motivational Speaker Interest Form
Share your story, areas of impact, community resources, and references so we can consider you as a guest speaker for Rose in Concrete.
Community Organization Name
What services do you have to offer our youth and/or what topic can you educate our youth about?
Would you like to come in as a motivational speaker and tell your story?
Yes
No
What challenges have you overcome that shaped who you are today?
Justice involvement / arrest / incarceration
Poverty or financial hardship
Trauma or childhood challenges
Substance use or recovery journey
Mental health struggles
Abuse or domestic violence
Loss of a loved one
Educational challenges
Other
Have you ever been justice impacted (arrested, incarcerated, involved with the legal system, or impacted by someone close to you being justice involved)?
Yes
No
If yes, how did this experience shape your growth?
Why do you believe your story could positively impact youth in our program?
Have you previously worked with youth, schools, mentorship programs, or community organizations?
Yes
No
If yes, please briefly explain your experience.
Are you interested in joining Rose in Concrete as a one-time guest speaker or a consistent community partner?
One-time speaker
Monthly/ongoing partner
Open to discussing options
Reference 1
Reference Name
Relationship to You
Reference Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Email
example@example.com
Reference 2
Reference Name
Relationship to You
Reference Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Email
example@example.com
Is there anything else about your journey, experience, or passion you would like us to know?
What is your story, and what message do you want our youth to hear?
What topics or lessons are you most passionate about sharing with young people?
Making better choices
Accountability and responsibility
Leadership
Overcoming adversity
Self-worth and confidence
Healthy relationships
Education/career success
Mental health and healing
Other
Submit Application
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