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
*
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?
*
Event Information
Venue
*
Where will the event take place?
Preferred date
*
-
Month
-
Day
Year
Date
Alternate date
*
-
Month
-
Day
Year
Date
Preferred time
*
Is Venue Handicap Accessible?
*
Yes
No
Parking Information
*
Contact number for day of event
*
Mobile Number
PaymentData
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
Honorarium (In person)
$
360.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
*
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: