First Name Last Name Email Phone What is your title/role at your organization? Organization/School Name (no abbreviations) ex: University of California, Los Angeles (not UCLA) Organization/School Street Address Organization/School City Organization/School State/ProvincePlease select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY NL PE NS NB QC ON MB SK AB BC YT NT NU Other: Organization/School Zip Code Enter "other" State/Province here: Organization Details Please provide a description of your event, learning objectives, event goals and/or the speaker's expected role. Not sure? That's okay! We're happy to help you plan. Organization TypeK-8High SchoolCollege/UniversityProfessional/CorporationFoundationNonprofit/NGOGovernment/MilitaryHealthcare or Treatment CenterSchool System/District Are you an Active Minds chapter member or Advisor?YesNo How did you hear about Active Minds? Please select... Internet search Active Minds website Social media Conference/networking event Email/marketing piece Referral from a friend or colleague I’m a chapter member Other Please let us know who, if anyone, referred you to this program. Event Details Which type of event format are you interested in hosting?Virtual EventIn-Person Event Will your event address be different from your organization/school address?YesNo Event Street Address Event City Event State/ProvincePlease select... AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY NL PE NS NB QC ON MB SK AB BC YT NT NU Other: Event Zip/Postal Code Enter "other" Event State/Province here: Which speaker(s) are you interested in hosting? Abraham Sculley Aisha Moore Alison Malmon Anthony Sartori Becky Fein Brandon Bond Carli Bushoven Colleen Coffey David Romano Dayna Altman Donovan Taylor Hall Dr. Kristen Lee Frank Warren Greg Vogt Ivy Watts Jade Mathis Jiggy Yoon Kai Roberts Kevin Birthia Kevin Briggs Meg Hutchinson Michael Zibilich Pablo Campos Stacy Pershall Unsure Who is your target audience? (check all that apply) College students Community members Faculty/Staff (educators) Healthcare Workers Managers/Employees Parents/Caregivers Professionals Students (high school) Students (K-8) Veterans/Active duty service members Other What is the focus of your event? (check all that apply) Anxiety/Panic Disorder Asian American Mental Health Athletes Black, Indigenous, People of Color Mental Health Bipolar Disorder Bullying Depression Domestic Violence Eating Disorders Fraternities/Sororities K-12 Audience Latinx Mental Health LGBTQ+ Mental Health Life Transitions Men and Mental Health Mental Health and Current Events Mental Health and the Pandemic Mental Health Awareness Mental Health in the Workplace Mindfulness Music/Creativity and Mental Health Obsessive Compulsive Disorder Perfectionism Personality Disorders Post-Traumatic Stress Disorder Religious/Spiritual Communities Resilience Self-Care/Self-Compassion Self-Injury Sexual Assault/Rape Culture Stigma Reduction Stress Management Substance Use and Abuse Suicide Prevention Trauma Veterans/Active duty service members Women and Mental Health Other Other Target Audience What is your speaker budget?Please select... $0-500 $501-1,000 $1,001-2,000 $2,001-3,000 $3,001-4,000 $4,001-5,000 $5,001-10,000 $10,001+ If you are in need of funding, consider applying for the Active Minds Program Fund to support bringing a speaker to your community Would you also be interested in booking a Send Silence Packing event?Please select... Yes No Event Planning Information What is your 1st preferred date for your event? What is your 2nd preferred date? Preferred time of presentation? Have you previously hosted an Active Minds Speaker? Please select... Yes No Previously Hosted SpeakerPlease select... Kevin Briggs Carli Bushoven Pablo Campos Diana Chao Colleen Coffey Becky Fein Meg Hutchinson Dr. Kristen Lee Alison Malmon Stacy Pershall Kai Roberts David Romano Abraham Sculley Ivy Watts Greg Vogt Frank Warren Michael Zibilich Does your organization require the use of its own performance agreement/contract?Please select... Yes No Billing Contact First Name Billing Contact Last Name Billing Contact Title/Role Billing Contact Email Address Contact Information
