Brownsburg Public Library Registration

Attendance Request Form – Survivor Speakout – Brownsburg Public Library

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 $42.00 fee with a debit or credit card securely through PayPal. You do not need a PayPal account to pay your fee. If you have problems submitting this form, please call 317.289.3242.

Please do not contact the library about attending the Survivor Speakout Victim Impact Panel. Contact Survivor Speakout directly with questions. Enter the library through the east entrance, not the main entrance.

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

Read the guidelines to attend in person

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 at the Brownsburg Public Library

Date *Choose a date to attend IN PERSONJanuary 14th - 10:00am-12:00pmApril 8th - 10:00am-12:00pm

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

If your charge is not listed above and you chose 'Other', please tell us why you were arrested in the field below.

Your probation officer and date your probation ends

Probation officer *Choose oneAndrew LillpopAshley StarlingBetsy SchulerBen NeureiterBrittany StodghillCaleb NanzerCarmen SimsCarol NienaberCassie McDanielCheryl KochChad KoebckeChad UlmerChantel CloudChristina CandiaCorey WalkerCourtney SacchiniDwight StevensonElizabeth KriegFaith EdwardsFaith OliverJesse TuckerJustin CulpKevin McCleeseKristin UshmanLeah BakerMalachi TaylorMariah MyersMcKinzee TerryMegan CarusoMegan MorgusonMelody SearsPatrick GillianRebecca ShrockReid RoetheRichard PorterRichard MartinezRonda GibsonShelby WiserStephen OwensSteve RobertsSusan BentleySuzan Shrock-GideonThomas PurkhiserTim MillerZach MinardoMy probation officer is not listedI do not know my probation officer's nameI have a plea/diversion agreement

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