MSU Center for Survivors Community Outreach Request Form

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Please complete the form below. Direct your questions to Tana Fedewa, Center for Survivors Director at adamstan@msu.edu

Email *

Type of Request *

Presentation

Safe Space (SACI Volunteers attend your event and provide crisis intervention in case survivors are triggered)

Crisis Intervention

Resource Fair

Other:

Required

Are you requesting a Professional Staff or a SACI Volunteer? *

Sexual Assault Crisis Intervention Volunteers

Center for Survivors Staff

Name of Event *

Date of the Event *

YYYY

Time of the Event *

Time

Anticipated Length of presentation *

30 minutes

45 minutes

1 hour

2 hours

Other:

Location of Event *

Event Description *

Expected Audience *

Students

Faculty

Staff

Community Members

Other:

Required

Estimated number of attendees *

5-10

10-20

20-30

More than 50

Other:

Contact Person *

Email address *

Phone Number *

The date of this request *

YYYY

You must submit requests 2 weeks before the actual event. We will make every effort to fulfill your request, if we are not able to we will notify you. *

I agree

Other:

Additional Comments or Information

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