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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
Who is the audience for this request?
Special Interest Group
Would you like information from a specific Someplace Safe program?
Crime Victim Advocacy Programs
Safe Harbor/ Human Trafficking Programming
Parenting Time Centers
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
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.
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.
No - No fee required
No - Fee will be waived fort Someplace Safe
Yes - Fee is required/requested (please indicate amount below in 'other')
N/A - This request is for a PRESENTATION
Please note any additional questions, special requests, or information here.
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