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OutSpoken Youth Educator

Contact Information: (Please print clearly)

Name:__________________________________________________ Today’s date:__________
Telephone Number: _______________________________ Type: ___________________________
Ok to Call?  Yes  No Ok to text?  Yes  No Ok to leave a voicemail?  Yes  No
Email:___________________________________ Contact Notes:_______________________________
City: __________________ State: ____ Zip Code: ____________

Age: _______ Date of Birth: ________/_________/________ Pronouns:______________

Gender: _________________________ Sexual Orientation:_________________________
Race: __________________________ Ethnicity: _______________________________
Do you identify as having a disability? If so are there any ways we can make
programming more accessible to you? ____________________________________________

Do you have permanent housing?_________________________________________________

Who do you currently live with and what’s your relationship to them? List everyone if
possible. (ie mom, step dad, foster parents, siblings, friend):

Total income of entire household:__________________________________________________

Are you eligible for free/ reduced-price lunch and/or public benefits? _______________

What language(s) are primarily spoken in home?___________________________________

Are you a refugee or immigrant? Yes No Unknown

Are you in school now? If yes, which school and year? ______________________________
OutSpoken Youth Educator
Self Evaluation

What experiences, interests and/or skills are you comfortable and knowledgeable to
speak about (this helps us decide who to put on specific panels). Please check all
that apply:
□ Experiences around school □ Dealing with parents □ Coming out
□ Gender-related issues □ Bullying □ Religion
□ Sexuality-related issues □ Homelessness □ Poverty
□ Immigration □ Race □ Disability
□ Families that aren’t married □ Foster care □ Healthy relationships
□ Siblings □ Drugs and alcohol □ Suicide
□ Depression □ Relationship violence □ Leadership
□ Other things:____________________________________________________________________

What are two goals you have for yourself in the next year?



What would help you feel prepared to speak on a panel?

What are ways you feel the NW Network can best support you?

Any additional information you would like to share with the program or feel would be
helpful for us to know?
OutSpoken LGBTQ Youth Speaker’s Bureau a program of
The Northwest Network of Bisexual, Trans, Lesbian & Gay Survivors of Abuse
Statement of Rights

1) Every participant has the right to considerate and respectful treatment

regardless of race, color, religion, marital status, ethnicity, sexual or gender
identity, lifestyle, political ideology, legal status, economic status, physical
status, disability or national origin.

2) Every participant has the right to determine their needs and discontinue
participation in the program at any time.

3) Every participant has the right of access to the NW Network record of

information concerning them. A participant may schedule an appointment to
review this record of information. The NW Network maintains only basic
necessary program related information for the OutSpoken Program and will not
share your contact information without expressed permission.

4) A participant has the right to file a complaint with The NW Network if they feel
their rights have been violated. The participant should use the grievance
procedure outlined below. Each participant has the right of appeal in any
recommendation, opinion, or decision that is the outcome of the grievance
Grievance Procedure

A grievance that cannot be resolved between a program participant and NW

Network staff members, should be directed to the Staff Supervisor for assistance. If
the participant is dissatisfied with the outcome, the issue will then be taken to the
Executive Director of The NW Network, who will problem solve and work to resolve
the issue. If the issue is still not resolved satisfactorily it may be brought to the Chair of
the Board of Directors of the NW Network, who will then bring it to the Board of
Directors for discussion and resolution. Participants will be notified of this policy while
informed of participant rights. This policy will be posted in the agency & included in
the Participant Packet.

Agreement for Participation:

I understand that I when I am representing OUTSpoken I am expected to be
respectful with other panelists, staff and facilitators. In exchange for my
participation, the Northwest Network will compensate me for my time unless
otherwise agreed upon. I understand I have right to exit the program whenever I see

OUTSpoken Participant/Date
For more information or questions contact The Northwest Network of Bi, Trans, Lesbian & Gay Survivors of Abuse:
206-568-7777 (phone)