Contact Information Name * Phone * Email * Organization * Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Presentation Type Are you a Elementary School Middle School High School College Professional Group Community Group School Presentations Teen Dating Violence Healthy Relationships Sexual Harassment Media Literacy Bystander Intervention Sexual Assault Drug Facilitated Sexual Assault Topic(s) of interest Bystander Intervention Consent Domestic Violence Healthy Relationships Human Trafficking Internet/Social Media Safety LGBTQ+ Communities Media Literacy Sexual Violence Teen Dating Violence Toxic Masculinity/Gender Inequity Violence Involving Pets Professional Presentations SERV Services Overview Domestic Violence Awareness Sexual Violence Awareness SART/DVRT Procedures Sexual Violence Prevention/Bystander Prevention Sexual Harassment Media Literacy This event is a(n) Community Tabling Educational Workshop Film Screening Organizational Training Speaking Engagement Community Presentations SERV Services Overview Domestic Violence Awareness Sexual Violence Awareness Sexual Violence Prevention/Bystander Prevention Information Table Will table and chairs be supplied? Yes No If this is an outdoor event, is there a rain date? Yes No Rain Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Approximate number of attendees: * Presentation Date and Time Date of Presentation Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Time of Presentation Hour Hour123456789101112 : Minute Minute00153045 am pm Presentation Needs What tech materials do you need us to bring? Projector Movie Screen Computer/Laptop Microphone Speakers Other (please specify) What tech materials do you need us to bring? Other (please specify) What setup materials do you need us to bring? Chairs Table Tent Other (please specify) What setup materials do you need us to bring? Other (please specify) Which of the following will be readily available for use? Power Outlets/Extension Cords Wi-Fi Connectivity Do your guests need any special accommodations? If so, please explain.
