GLSEN's Safe Schools Advocacy Summit (SSAS) - March 27-29, 2011 - Washington DC. Students and adults from across the country will participate in workshops learning about safe schools legislation, advocacy and organizing skills, and strategies to continue to work for safe schools at the school, local, state and federal levels. On the final day participants will go to Capitol Hill to lobby their representatives and senators about the importance of safe schools issues.

First Name:

Required

Last Name:

Required

Preferred Name:
If you prefer for us to use a name that is different from your first name, provide that here.


Home Address (where you are registered to vote, if applicable):

Required

City

Required

State

Required

ZIP Code

Required

Email: Please check spelling carefully

Required

Home Phone:


Cell Phone:


Final applicants may be interviewed over the phone. Please indicate which number we should use if we need to contact you.
Home
Cell


FOR CURRENT STUDENTS: GLSEN requires each student chosen to attend the Safe Schools Advocacy Summit and their legal parent or guardian to sign a Participant Agreement form (GLSEN will send separately).
Yes, I understand this requirement.

Required

Which name should we use when contacting you?
First name
Preferred name

Required

Date of Birth (mm/dd/yyyy):

Required

Do you have a current connection to school? If so, check all that apply:
Student
Parent
Teacher
Administrator
Other Educational Professional
Other (describe below)


If you selected "other" in the previous question about schools, please describe:


Are you going to be enrolled in a K-12 school for all or most of the 2010-2011 school year?
Yes
No

Required

FOR CURRENT HIGH SCHOOL STUDENTS: High School Graduation Year:


FOR CURRENT HIGH SCHOOL STUDENTS: School Name:


OPTIONAL IDENTITY INFORMATION:
Answering the following four questions is not required. However this information helps us in determining with whom we work and what communities are being served.

What is your gender identity and/or sex?


OPTIONAL IDENTITY INFORMATION:
Do you identify as transgender?
Yes
No


OPTIONAL IDENTITY INFORMATION:
What is your sexual orientation?


OPTIONAL IDENTITY INFORMATION:
What is your race/ethnicity?


Please indicate any current or past participation in any GLSEN programs, trainings or events.
Chapter member/Volunteer
JumpStart Student
GLSEN Ambassador
Safe Schools Advocacy Summit (SSAS) Alumni
Other (please describe below)


If you selected "other" in the previous question about participation, please describe:


Please note any personal experiences you have had with bullying and harassment, including work you have done to address bullying and harassment in schools.


Have you ever participated in lobbying, letter-writing campaigns, or other activities in which you communicated with elected officials? If so, please list them here.


Describe your organizing experience. Be sure to include any participation or leadership roles in school, community or issue-based organizations.


What experiences and/or skills will you contribute to SSAS?


Is there anything else you would like to share with us?