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?

Other
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
Are you looking for a JDNM presentation or are you having a tabling event?
Event Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Event Time

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Time of JDNM Presentation

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
Type of Audience
Estimated Number of Attendees
Would you like a Q&A session?
May we hand out JDNM material?
Will you have a counselor available for your attendees during and immediately following our presentation should the need arise?
Will you supply A/V equipment (microphone, speakers, projector & screen)?
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.

Thank you for your interest.
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
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