Brownsburg Public Library Registration

Survivor Speakout Victim Impact Panel Attendance Request Form – Brownsburg Public Library

DATES AVAILABLE
All Live In-Person Victim Impact Panels are from 9:45 A.M. to 12:00 P.M.
Space is limited.

Saturday, April 27
Saturday, May 18
Saturday, June 29
Saturday, July 27
Saturday, August 31
Saturday, October 12
Saturday, November 9
Saturday, November 30

REGISTER TO ATTEND

The form below is 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 $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. If you have problems submitting this form, please call 317.289.3242.

NOTE: Enter the library through the east entrance, not the main entrance. 450 S Jefferson Street, Brownsburg, Indiana 46112. The panel will be in the Pearson Room; first door on the right as you enter the east entrance.

Read the 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

Telephone *

Email *

Email

Confirm Email

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

Request the date you would like to attend Survivor Speakout IN PERSON at the Brownsburg Public Library. All panels are from 9:45 A.M. to 12:00 P.M.

Date *Choose a date to attend IN PERSONSaturday, April 27, 2024Saturday, May 18, 2024Saturday, June 29, 2024Saturday, July 27, 2024Saturday, August 31, 2024Saturday, October 12, 2024Saturday, November 9, 2024Saturday, November 30, 2024

The Brownsburg Public Library is not sponsoring or endorsing the subject matter of this meeting.

On what charges were you arrested?

Charge *Choose oneDWIDUIOWIOUIPIMinor in ConsumptionOpen ContainerIllegal possession of alcoholDrug RelatedOther

Your probation officer and date your probation ends

Probation officer *Choose oneAbigail O’BrianAlex RedmanAndrew LillpopAshley StarlingBetsy SchulerBen NeureiterBrittany StodghillCaleb LazanoCaleb NanzerCarmen SimsCarol NienaberCheryl KochChad KoebckeChad UlmerChantel CloudChristina CandiaCorey WalkerCourtney SacchiniDwight StevensonElizabeth KriegErinn McCluneyFaith EdwardsFaith OliverJana SchwindtJesse 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

Date 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 oneI do not live in Indiana.AdamsAllenBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFranklinFultonGibsonGrantGreeneHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLakeLaPorteLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNewtonNobleOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushSt. 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 outside of Indiana, list the county 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

GUIDELINES *

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

This is a graphic presentation *

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

Submit

Please, do not contact the library about attending the Survivor Speakout Victim Impact Panel. The Brownsburg Public Library is not sponsoring or endorsing the subject matter of this meeting. Contact Survivor Speakout directly with questions. 317.289.3242