Online Live Victim Impact Panel

Live Online Survivor Speakout Victim Impact Panel

Survivor Speakout Online is a 2-hour live presentation, not a recorded class. You will not be tested.

This form is for OFFENDERS 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 $55.00 fee.

Read the guidelines to attend ONLINE

Tuesday, June 13th – 10am-12pm – ONLINE
Saturday, June 17th – 10am-12pm – ONLINE
Thursday, June 29th – 6pm-8pm – ONLINE
Thursday, July 6th – 6pm-8pm – ONLINE
Tuesday, July 26th – 10am-12pm – ONLINE
Wednesday, August 23rd – 6pm-8pm – ONLINE
Tuesday, September 12th – 10am-12pm – ONLINE
Wednesday, September 21st – 6pm-8pm – ONLINE
Thursday, September 27th – 10am-12pm – ONLINE
Thursday, October 5th – 6pm-8pm – ONLINE
Wednesday, October 18th – 6pm-8pm – ONLINE
Wednesday, November 1st – 6pm-8pm – ONLINE
Thursday, November 9th – 10am-12pm – ONLINE
Tuesday, November 14th – 6pm-8pm – ONLINE
Thursday, December 14th – 10am-12pm – ONLINE

GUIDELINES *

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

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 *

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

Date *Choose a date to attend ONLINETuesday, June 13th - 10am-12pmSaturday, June 17th - 10am-12pmThursday, June 29th - 6pm-8pmThursday, July 6th - 6pm-8pmWednesday, July 6th - 10am-12pmWednesday, August 23rd - 6pm-8pm Tuesday, September 12th - 10am-12pmThursday, September 21st - 6pm-8pmWednesday, September 2712th - 10am-12pmThursday, October 5th - 6pm-8pmWednesday, October 18th - 6pm-8pmWednesday, November 1st - 6pm-8pmThursday, November 9th - 10am-12pmWednesday, November 14th - 6pm-8pmThursday, December 14th - 10am-12pm

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 oneAlexandria RedmondAndrew LillpopAshley StarlingBetsy SchulerBen NeureiterBrittany StodghillCaleb NanzerCarmen SimsCarol NienaberCheryl KochChad KoebckeChad UlmerChantel CloudChristina CandiaCorey WalkerCourtney SacchiniDwight StevensonElizabeth KriegErinn McCluneyFaith EdwardsFaith OliverJesse TuckerJustin CulpKevin McCleeseKristin UshmanLeah BakerMalachi TaylorMariah MyersMcKinzee TerryMegan CarusoMegan MorgusonMelody SearsPatrick GillianRebecca ShrockReid RoetheRichard PorterRichard MartinezRonda GibsonShelby WiserStephen OwensSteve RobertsSuzan Shrock-GideonThomas PurkhiserTim MillerZach MinardoMy probation officer is not listedI do not know my probation officer's nameI have a plea/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 oneThe 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 listedI do not know my judge's name

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 oneAdams Allen Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. JosephScott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley

In which county do you live? *Choose oneAdams Allen Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. JosephScott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley

To attend online, upload a recent, clear headshot photo of yourself (Only .jpg, jpeg, .png, .gif files that are less than 2MB allowed)

Click or drag files to this area to upload. You can upload up to 2 files.

We must have a recent, clear headshot photo of you to attend ONLINE or you must register to attend IN PERSON.

COMMENTS / QUESTIONS

Submit Registration Request