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Speaking Event Host Application

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/Province

Organization/School Zip Code

Enter "other" State/Province here:

Organization Details

Organization Type

K-8High SchoolCollege/UniversityProfessional/CorporationFoundationNonprofit/NGOGovernment/MilitaryHealthcare or treatment centerSchool System/District

Are you an Active Minds chapter member or Advisor?

YesNoNo, but I would like to collaborate with an Active Minds chapterNo, but I am interested in starting a chapter

How did you hear about Active Minds?

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/Province

Event Zip/Postal Code

Enter "other" Event State/Province here:

Which speaker(s) are you interested in hosting?

Kevin Briggs	Carli Bushoven	Pablo Campos
Diana Chao	Colleen Coffey	Becky Fein
Lisa Hamp	Meg Hutchinson	Juliana Kerrest
Dr. Kristen Lee	Alison Malmon	Stacy Pershall
Javier Cabrera-Rosales	Kai Roberts	David Romano
Abraham Sculley	Greg Vogt	Frank Warren
Michael Zibilich	Unsure

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.

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
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?

Event Planning Information

What is your 1st preferred date for your event?

What is your 2nd preferred date?

Have you previously hosted an Active Minds Speaker?

Previously Hosted Speaker

Does your organization have an affiliation with a hotel or other local accommodations?

Does your organization require the use of its own performance agreement/contract?

Billing Contact First Name

Billing Contact Last Name

Billing Contact Title/Role

Billing Contact Email Address

Contact Information

Active Minds is the nation's premier nonprofit organization supporting mental health awareness and education for students.

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Active Minds is a 501c3 charitable organization.

Our CFC number: 16455
Our Tax ID number: 20-0587172

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