Keeping the Stories Alive (Survivors Speak)
Complete the form below for survivors and second and third generation survivors to come to your school to share their stories. Please contact Patricia Dipette at pdipette@jfedgmw.org if you have questions.
Your Information
Name
*
First Name
Last Name
E-mail
*
Confirmation Email
example@example.com
Subject(s) you teach
School/Organization Information
Name
*
Which grade(s) are the students in?
*
Please enter if you are completing this form on behalf of a school
Phone
*
Format: (000) 000-0000.
E-mail
*
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
How many attendees/students?
*
Please provide us with a brief understanding of how much Holocaust knowledge the students have.
*
Event Information
Venue
*
Where will the event take place?
Preferred date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Alternate date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred time
*
Is Venue Handicap Accessible?
*
Yes
No
Parking Information
*
Contact number for day of event
*
Mobile Number
Format: (000) 000-0000.
PaymentData
Are you a Title 1 school?
*
Yes
No
Please select from the formats below
*
Virtual
In person
The Holocaust Council appreciates your honorarium. Please select one of the payment methods below. An invoice will be provided
*
Check
Credit Card
Payment Information
*
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( X )
Honorarium (Virtual)
$180.00
$
180.00
Honorarium (In person)
$360.00
$
360.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
*
I understand that my/our picture may be taken at this event and it may appear on various channels, including social media and the Federation website.
SUBMIT
Form Name
Should be Empty: