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?

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

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

Date of Event

Date

Time of Event

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option

Time of JDNM Presentation (If different than time of event)

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option

Audience

(Grade, Faculty, Coaches, etc)

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 students during and immediately following our presentation should the need arise?

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

Do you have a budget for this presentation?

What is your budget amount?

Feel free to leave any other additional information or questions.

Our Safe Student Initiative program relies on funding from schools, individuals, businesses, organizations and foundations. We are happy to work with you to bring this program to your school.

Thank you for your interest.

Do you have a budget for this presentation?

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 *