Virtual Online Live Victim Impact Panel Registration

Virtual, Live Online Survivor Speakout Victim Impact Panel – Accepted Nationwide*
You cannot attend online with your cell phone!

Register by completing form below. *Oklahoma and Arkansas do NOT accept virtual, online panels. 

Times are EST (Eastern Standard Time) Space is limited. You must provide true and accurate information when you register.

Read the full guidelines to attend ONLINE

Survivor Speakout Victim Impact Panels are accepted by court systems nationwide. Survivor Speakout online is a 2-hour live online presentation, not a recorded class, and there is no test.

NOTE: You cannot attend online using your cell phone. You must have a reliable internet connection and an iPad, Android tablet, laptop or personal computer to attend a Survivor Speakout victim impact panel online. 

The form below is to request to attend Survivor Speakout Victim Impact Panel ONLINE. Once the form has been submitted you will be directed to a page to pay your $50.00 fee. You will receive a confirmation email after submitting this form. If you do not receive the confirmation email, check your spam/junk folder.

You will be considered a “No Show” if you are late or fail to attend the date you chose to attend. You must reschedule and pay an additional fee if you are a no show for any reason. There are NO REFUNDS.

Your IP address will be recorded with this submission. Complete this form to register.

Request the date you would like to attend a virtual Survivor Speakout Victim Impact Panel

*Oklahoma and Arkansas do NOT accept virtual, online panels.

Date *Choose a date to attend a virtual online panelTuesday, June 24 - 5:45pm-8pmTuesday, July 8 - 5:45pm-8pmThursday, July 31 - 9:45am-NoonTuesday, August 12 - 5:45pm-8pmThursday, August 28 - 9:45am-NoonTuesday, September 9 - 9:45am-NoonWednesday, September 24 - 5:45pm-8pmThursday, October 9 - 9:45am-NoonTuesday, October 21 - 5:45pm-8pmThursday, November 13 - 9:45am-NoonThursday, November 13 - 5:45pm-8pm

Technology required *

• I understand that I CANNOT use a cell phone to attend Survivor Speakout online and that I must use an iPad, tablet, laptop or personal computer (PC).

Guidelines *

• I have read and understand all of the Survivor Speakout Guidelines to attend ONLINE USING ZOOM

First Name / Last Name *

First

Last

Your Home Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

If Last a

Email *

Email

Confirm Email

Telephone *

On what charges were you arrested?

Charge *Choose oneDWIDUIOWIOUIPIMinor in ConsumptionOpen ContainerIllegal possession of alcoholDrug RelatedOther

If you chose 'Other' above, please tell us what you were charged with

Your probation officer

Probation officer *Choose oneAbigail O’BrienAlex RedmanAmber HoffertAndrew LillpopAshley StarlingBetsy SchulerBen NeureiterBrandon FowlerBrian DayBrittany StodghillCaleb LazanoCaleb NanzerCarmen SimsCarol NienaberCaroline CathcartChad BoruffCheryl KochChad KoebckeChad UlmerChantel CloudChristina CandiaCorey WalkerCourtney SacchiniDwight StevensonElizabeth KriegErinn McCluneyFaith EdwardsFaith OliverJamie WodtkeJana SchwindtJesse TuckerJohni TaylorJustin CulpKatrina SkeltonKevin McCleeseKristin UshmanLeah BakerMakayla HuseMalachi TaylorMariah MyersMcKinzee TerryMegan CarusoMegan MorgusonMelody SearsPatrick GillianRebecca ShrockReid RoetheRichard PorterRichard MartinezRonda GibsonShelby WiserStephen OwensSteve RobertsSuzan Shrock-GideonThomas PurkhiserTim MillerZach MinardoMy probation officer is not listed.I do not know my probation officer's name.I have not been assigned a probation officer. I have a diversion agreement.

If your probation officer's name is not listed, enter their name here

Who is the judge presiding over your case?

Judge *Choose oneI do not know my judge's nameThe judge presiding over my case is not listed belowThe Honorable Rhett StuardThe Honorable Dan ZielinskiThe Honorable Mark SmithThe Honorable Stephanie Lemay-LukenThe Honorable Charles E. HostetterThe Honorable David ColemanThe Honorable Travis CraneThe Honorable Lindsay R. WalkerThe Honorable James D. SpencerThe Honorable Maureen T. OwenThe Honorable Bruce E. PetitThe Honorable J. Jeffrey EdensThe Honorable Matt HeadleyThe Honorable Tammy SomersThe Honorable Clayton A. GrahamThe Honorable Amy JonesThe Honorable Ryan Tansel

If you know the name of your judge, but they are not on the list, enter it here

Your age *Choose one15-1819-2526-3031-3536-4041-4546-5051-5556-6061-6566-7071-7576-8081-8586-9091-9596-100

County information

In which county were you arrested, charged or convicted? *Choose oneI live outside of IndianaAdamsAllenBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFranklinFultonGibsonGrantGreeneHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLakeLaPorteLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNewtonNobleOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushSt. JosephScottShelbySpencerStarkeSteubenSullivanSwitzerlandTippecanoeTiptonUnionVanderburghVermillionVigoWabashWarrenWarrickWashingtonWayneWellsWhiteWhitley

If outside of Indiana, list the city, county and state where you were arrested, charged or convicted

In which county do you live? *Choose oneMy county is outside of IndianaAdamsAllenBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFranklinFultonGibsonGrantGreeneHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLakeLaPorteLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNewtonNobleOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushSt. JosephScottShelbySpencerStarkeSteubenSullivanSwitzerlandTippecanoeTiptonUnionVanderburghVermillionVigoWabashWarrenWarrickWashingtonWayneWellsWhiteWhitley

If you live outside of Indiana, list the city, county and state where you live

How did you hear about Survivor Speakout

• My probation officer
• My attorney
• Online search
• Other

If you chose "Other" above, tell us how you heard about Survivor Speakout?

This is a graphic presentation *

• I understand that the Survivor Speakout Victim Impact Panel is graphic in nature dealing with death

PHOTO ID *

• I understand that I will be asked to present my photo ID

Comments/Questions

What number comes after 6?

Subtítulos de traducción al español

• Me gustaría solicitar subtítulos de traducción del inglés al español cuando asista.

Submit

Contact Survivor Speakout directly with questions. 317.289.3242