Community Outreach Event Application

Organization Name*
ie. School, Club, Company etc.
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name*

First NameLast Name
Contact Email*
example@example.com
Contact Phone *

Area CodePhone Number
How did you hear about us?*

Company/SponsorEnewsletterFlyerFriend/FamilyPrint MediaRadioSocial MediaVoice2Change PodcastWebsiteOther
Name of Friend/Family Member*

First NameLast Name
Name of Company/Sponsor*
Event Name
Venue Name (If different than Organization name.)
Venue Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Event Date*

MonthDayYear
Date
Event Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Time of JDNM Presentation*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Type of Audience*
Estimated Number of Attendees*
Would you like a Q&A session?*

YesNo
May we hand out JDNM material?*

YesNo
Will you have a counselor available for your attendees during and immediately following our presentation should the need arise?*

YesNo
Will you supply A/V equipment (microphone, speakers, projector & screen)?*

YesNo
Covid-19 Disclaimer
Jane Doe No More staff, volunteers and their sponsors cannot guarantee a Covid-19 free environment. We will not require proof of vaccination or the use of masks from staff, volunteers or participants.

I First Name Last Name , on behalf of Name of Organization and Name of Venue acknowledge and understand the contagious nature of COVID-19 and exposure or infection may result in personal injury, illness, permanent disability, and death. I hereby covenant and agree to defend, indemnify and hold harmless Jane Doe No More staff, volunteers and their sponsors against any and all liability, loss, damages, claims, or actions (including costs and attorney's fees) of any nature or kind including those for bodily injury, to the extent permissible by law, arising out of or in connection with hosting a Community Outreach Presentation.

Signature
What is your budget for this presentation?*
Feel free to leave any other additional information or questions.
Our Community Outreach program relies on funding from individuals, organizations, and businesses. We are happy to work with you to bring this program to your community.

We will provide flyers and promote the event via our active social media channels to get the word out. We look forward to working with you.

Thank you for your interest.
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