Hendricks County 4H Complex & Conference Center Registration

Attendance Request Form – Survivor Speakout Victim Impact Panel – Hendricks County 4H Complex & Conference Center

This form is for OFFENDERS to request to attend Survivor Speakout Victim Impact Panel IN PERSON. Once the form has been submitted you will be directed to a page to pay your $45.00 fee with a debit or credit card securely through PayPal.

Read the guidelines to attend in person

Wednesday, December 6, 2023 – 6:30pm-8:30pm
Wednesday, March 6, 2024 – 6:30pm-8:30pm
Wednesday, June 5, 2024 – 6:30pm-8:30pm
Wednesday, September 4, 2024 – 6:30pm-8:30pm
Wednesday, December 4, 2024 – 6:30pm-8:30pm

Location – Hendricks County 4H Complex & Conference Center

There are also ONLINE victim impact panels available to attend as well as in person panels at the Brownsburg Public Library.

Do not call or contact the Hendricks County 4H Complex & Conference Center for information. Contact Survivor Speakout. 317.289.3242

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

GUIDELINES *

• I have read and understand the Survivor Speakout Guidelines to attend IN PERSON

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 IN PERSON

Date *Choose a date to attend IN PERSONWednesday, December 6, 2023 - 6:30pm – 8:30pmWednesday, March 6, 2024 - 6:30pm – 8:30pmWednesday, June 5, 2024 - 6:30pm – 8:30pmWednesday, September 4, 2024 - 6:30pm – 8:30pmWednesday, December 4, 2024 - 6:30pm – 8:30pm

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’BrianAlexandria RedmondAndrew LillpopAshley StarlingBetsy SchulerBen NeureiterBrittany StodghillCaleb LazanoCaleb 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

COMMENTS / QUESTIONS

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