TBTN Chapter Interest Form

TBTN Chapter Interest Form

Take Back The Night Chapters are comprised of at least 5 members. Option for each member to pay $15 for a signature TBTN T-shirt. Chapters hold at least one annual TBTN Event. Chapters receive Event planning support and other benefits from TBTN. Chapters actively support TBTN's work to end sexual violence and support survivors. Complete this form to confirm your interest in forming a TBTN Chapter. Please note in completing this form, you understand and agree that TBTN may use your submission and data as part of its aggregate reporting, operations, and internal review. TBTN does not sell your personal data or contact information to any 3rd parties.
Your Name*

First NameLast Name
Affiliated School, Organization, Business, or Other Entity*
Your School/Organization Email*
example@example.com
Your Cell Number (US Country Code = +1; Canada Country Code = +1; Australia Country Code = +61; UK Country Code = +44; find other Country Codes at https://countrycode.org/) *

Country CodeArea CodePhone Number
Your Personal Email*
example@example.com
How did you hear about Take Back The Night?

Google searchTBTN newsletterTBTN social mediaI have participated in a TBTN eventI have organized a TBTN eventSomeone I know was involved with TBTNSomeone at my institution recommended itOther
I understand the following requirements to become a TBTN Chapter:
- At least 5 members
- Advisor for the Chapter who is a full-time employee of the affiliated entity (for school-affiliated chapters only)
- Commitment to holding at least one TBTN Event each academic year
We can accomplish the above requirements.*

YesNo
Would you like to become a TBTN Fan (free) and receive our monthly newsletter?*

YesNo
Please list any additional comments or questions here.
Should be Empty: