Online Live Victim Impact Panel Registration

Live Online Survivor Speakout Victim Impact Panel – Accepted Nationwide

DATES AVAILABLE
Space is limited. Register by completing form below.

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 must have a reliable internet connection as well as a reliable laptop or computer to attend Survivor Speakout victim impact panel online. Cell phones are not acceptable. If you do not have a laptop or computer do not register to attend a Survivor Speakout online panel.

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 $40.00 fee. You will receive a confirmation email after submitting this form. If you do not receive the confirmation email, check your spam/junk folder.

Complete this form to register.

Technology required *

• I understand that I must have a laptop or computer to attend online ONLINE USING ZOOM and my cell phone must be turned off during the panel

Your Personal Information

Last Name / First Name *

First

Last

Address *

Address Line 1

City

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

Zip Code

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

Telephone *

Email *

Email

Confirm Email

Request the date you would like to attend Survivor Speakout ONLINE LIVE

Date *Choose a date to attend ONLINEWednesday, August 14th - 6pm-8pmFriday, August 30 - 10am-NoonTuesday, September 10 - 6pm-8pmSaturday, September 21 - 10am-NoonThursday, October 10 - 6pm-8pmTuesday, October 29 - 6pm-8pm

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 and date your probation ends

Probation officer *Choose oneAbigail O’BrianAlex RedmanAmber HoffertAndrew LillpopAshley StarlingBetsy SchulerBen NeureiterBrian DayBrittany StodghillCaleb LazanoCaleb NanzerCarmen SimsCarol NienaberCaroline CathcartChad BoruffCheryl KochChad KoebckeChad UlmerChantel CloudChristina CandiaCorey WalkerCourtney SacchiniDwight StevensonElizabeth KriegErinn McCluneyFaith EdwardsFaith OliverJana SchwindtJesse TuckerJustin CulpKevin 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

Date probation ends *

If you are not sure of the exact date, choose the last day of the month your probation ends

Who is the judge presiding over your case?

Judge *Choose oneI do not know my judge's nameThe Honorable Rhett StuardThe Honorable Dan ZielinskiThe Honorable Mark SmithThe Honorable Stephanie Lemay-LukenThe Honorable Charles E. HostetterThe Honorable Robert FreeseThe Honorable David ColemanThe 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 TanselThe judge presiding over my case is not listed

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

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 and state where you were arrested, charged or convicted

In which county do you live? *Choose oneI do not live in Indiana.AdamsAllenBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFranklinFultonGibsonGrantGreeneHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLakeLaPorteLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNewtonNobleOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushSt. JosephScottShelbySpencerStarkeSteubenSullivanSwitzerlandTippecanoeTiptonUnionVanderburghVermillionVigoWabashWarrenWarrickWashingtonWayneWellsWhiteWhitley

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

How did you hear about Survivor Speakout *Choose OneMy probation officerOnline searchMy attorneyOther

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

Comments/Questions

This is a graphic presentation *

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

Guidelines *

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

PHOTO ID *

• I understand that I must present my photo ID

Submit