Project Information Sheet s2

SpeakOUT UTEP Interest Form

Name: ______Phone #: ______Email: ______Department: ______Title: ______

Please Check One: UTEP faculty/staff Community Member Other ______

Are you interested in being a panelist speaker for an event(s)?

Yes No If yes, please check what areas you would feel comfortable speaking about. Dispelling Gay Myths HIV/AIDS Religion Bullying Straight alliances Gay Diversity LGBTQI Domestic Violence Issues Gay Empowerment Women’s & Men’s Health Issues Ethics Transgender/Transsexual Empowerment Homosexual Relationships Other ______Queer Leadership Other ______

What does it mean to you to be an LGBTQI member of society? ______In what ways would you like to contribute to the Queer Community here at UTEP? ______How can SpeakOUT UTEP assist you in accomplishing these goals? ______In what ways can SpeakOUT UTEP help better the El Paso/Juarez Communities? ______What would you like to accomplish as a panelist on SpeakOUT UTEP? ______

Student Development Center – 106 Union West – El Paso, Tx 79968 – (915) 747-5670 – fax: (915) 747-7400 h t t p : / / s t u d e n t a f f a i r s . u t e p . e d u / s d c ______

Student Development Center – 106 Union West – El Paso, Tx 79968 – (915) 747-5670 – fax: (915) 747-7400 h t t p : / / s t u d e n t a f f a i r s . u t e p . e d u / s d c