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Someplace Safe Community Awareness Request Form
What is the name and contact information for the Individual or Organization making the request? *
Please share your NAME / ORGANIZATION / PHONE # / ADDRESS / EMAIL ADDRESS
Your answer
Who is the audience for this request? *
Required
Would you like information from a specific Someplace Safe program? *
How many attendees do you anticipate? *
What is the date of the event? *
Request must be made AT LEAST 2 weeks ahead of time whenever possible
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YYYY
How long will the event be? *
Where would this event take place? *
Please share the specific LOCATION and ADDRESS, including city, state and zip code.
Your answer
If this request is ONLY for Someplace Safe to be present at a community event or have a 'tabling presence', is a registration fee required/requested? *
If Someplace Safe will be required to pay a fee, please indicate.
Required
Please note any additional questions, special requests, or information here.
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