HAVI Contact Form

HAVI Contact Form
Reason for Contact*

General Inquiry Regarding the HAVIHAVI ConferenceI Have Resources or Information to ShareMedia / PressMembershipSpeaking Invitation / Speaker RequestRequest a Letter of SupportTraining & Technical AssistanceWorking Group Inquiry
Do you have a deadline that is either today or tomorrow?*

YesNo
Please contact Andrea Maruniak, Sr. Manager of Communications at 573-424-6127
To Request Training & Technical Support from the HAVI please complete this request form
To submit an application for membership, please complete this form. If you have other questions about membership, working groups, or our conference, please send us your questions!
After you click the submit button, you will receive an electronic copy of Violence is Preventable: A Best Practices Guide for Launching & Sustaining a Hospital-based Program to Break the Cycle of Violence to the email address you indicate below.

If you are looking to speak with HAVI staff or receive more in-depth training & technical assistance, please select the "Training & Technical Assistance" option at the top of this form.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Media Outlet / Affiliation*
Thank you for sharing information with the HAVI! In the message box, please include any relevant links and a message summarizing why you are sharing this with us. If you have any specific files to upload, you may do so below.
About which working group do you have an inquiry?

Empowering the Front Line / Brave SpaceMental HealthPolicyResearch & EvaluationWorkforce DevelopmentReimagining the Public's SafetyMultiple Working Groups / Not Sure
The HAVI is always looking for talented people to join our team. If you're interested in working with us but don't see a current opening that fits your skills, please submit your resume and a brief description of your interest in working with the HAVI to be considered for future positions. If you want to apply to a specific position, please see current openings on our website.
To help us direct your request, please answer the following questions:
Organization / Affiliation*
Role/Title*
Are you affiliated with a HAVI Member Program?*

YesNo
Member Program*
In which of the following working groups have you actively participated over the last 12 months? (Check all that apply)*

Empowering the Front Line / Brave SpaceMental HealthPolicyResearch & EvaluationWorkforce DevelopmentReimagining the Public's Safety
Which of the following describes your request?*

Research StudyAdvocacy EffortOther Project
Latest date you can be sent your Letter of Support*

MonthDayYear
Date
In order to fulfill your request, we need a brief description of your research study, advocacy effort, or project as well as a draft letter with which to start.
Please describe your organization and/or the people you represent*

0/250
Describe the general purpose of your event including the target audience*

0/250

Describe the topic on which you would like the HAVI to speak*

0/250
List any specific speaker(s) at the HAVI you'd like to engage*
Type N/A if you want HAVI to find the best match
Format*

VirtualIn-PersonPre-Recorded
What platform?*
Eg. WebEx, Goto Meeting, Zoom, etc.
Are travel expenses covered?*

YesNo
Describe what travel expenses are covered and how they are covered*
Is there an honorarium involved?*

YesNo
Provide details regarding the honorarium*
Type of Speaking Engagement*

Keynote SpeakerMain Stage Non-Keynote SpeakerPanel ModeratorPanelistOther
Will the HAVI need to prepare slides?*

YesNoOnly If the Speaker Wants To
Will there be Q & A?*

YesNo
How much time should be dedicated to speaking vs. responding to Q&A?*
Date Range of Entire Event*
Date for the Speaking Request*

MonthDayYear
Enter the earliest date. If multiple dates are involved, indicate so below.
Estimated Length of Speaking Engagement*
Est amount of time in hours
Expected Start of Speaking Request

Optional - Enter if Known Minutes

AM/PM Option
Expected End of Speaking Request

Optional - Enter if Know Minutes

AM/PM Option
By what date do you need to confirm the name of our speaker?*

MonthDayYear
Our preference is to have at least 3 weeks notice
Would you like to be added to the HAVI newsletter to receive regular updates from the HAVI?*

Yes, subscribe me to the HAVI newsletterNo, Thank You
Message*
Brief description of your interest in working with the HAVI.
Upload Your Document(s)

Cancelof
Should be Empty:

	Yes	No	Not Sure
Medical Doctors / Clinicians
Researchers
Violence Prevention Professionals
Policy Makers
Students