Safe Student Initiative Host Application

School Name*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name*

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

Area CodePhone Number
How did you hear about our Safe Student Initiative program?*

Company/SponsorEnewsletterFlyerFriend/FamilyPrint MediaRadioSocial MediaVoice2Change PodcastWebsiteOther
Name of Company/Sponsor*
Name of friend/family member*

First NameLast Name
Event Name
(ie. Take Back the Night)
Venue Name (If different than school)
Venue Address (If different than school)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Event*

MonthDayYear
Date
Time of Event*

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
Audience*
(Grade, Faculty, Coaches, etc)
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 students 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 School   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 Safe Student Initiative Presentation.

Signature *
What is your budget for this presentation?*
Feel free to leave any other additional information or questions.
Our Safe Student Initiative program relies on funding from schools, individuals, businesses and foundations. We are happy to work with you to bring this program to your school.

Thank you for your interest.
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