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Take Back the Net: Speaker Registration
Date: Friday, April 2nd 2021 from 7 - 9 P.M. EST.
This event will be held via ZOOM webinar at the following link:

In honor of Sexual Assault Awareness Month, The Virginia Campus Task Force presents Take Back the Net, a virtual evening of support and healing for survivors and their allies. This form is for survivors who wish to verbally share their story in the virtual speak-out on zoom.

 The data collected here will only be viewed by confidential employees (listed below) and who are members of the planning committee for this event. It will not be shared with others and will kept confidential. Melissa or Dana will reach out to you for more information and next steps. If you have additional questions you can reach out to one of them or the representative from your university (who may not be confidential, depending on your school and their role).

Melissa Palguta (, University of Mary Washington
Dana Vandervelde (, Virginia Commonwealth University
Dr. Evelyn Whitehead (, Virginia State University
Julia Faett (, University of Mary Washington

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First Name, Last Name *
Pronouns *
Email Address (If a student, please use your university email) *
If a student, which Virginia/DC University are you affiliated with?
If a community member, what is your geographical location (i.e. Arlington, VA)
Please share the name you would like to go by (on zoom) the night of the event. If you’d like to remain anonymous you can choose any name you’d like. *
If you had to rank yourself from 1 - 10 in your healing process related to this experience, where would you be? (1= Have not worked through this experience, 10= Have done extensive personal work through this experience) *
What are some of the coping skills you use to manage stress/anxiety in the face of this experience? *
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