Virtual - Safe Student Initiative

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
Date of Event*

MonthDayYear
Date
Time of Event (30-60 minute presentations available)*

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

YesNo
Who would you like to be responsible for video communication? (ie. zoom, webex)*

Jane Doe No MoreMy School
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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