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Speaking Event Host Interest Form

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

Enter "other" State/Province here:

Organization/School Zip Code

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?

Provide your comment, question, or a description of your event.

Are you interested in hosting a virtual or in-person event?

Preferred speaker(s)

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

Preferred date

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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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