TBTN Chapter Formation Form

TBTN Chapter Formation Form

Complete this form to apply to become an official Take Back The Night Chapter. TBTN responds to applications within 2-5 business days. If you have any questions while completing this form, contact us at https://takebackthenight.org/contact/. 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
Your Prospective Role for Your Chapter (if applicable)

AdvisorPresidentOther
Your School/Organization Email*
example@example.com
Your Personal Email (Gmail, etc)*
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
Name of your affiliated school, college, military base, city, company, organization, or other entity*
Preferred Chapter Name (reference your affiliated school, college, military base, city, company, organization, or other entity, such as "University of Michigan TBTN Chapter" or "TBTN Chapter of Cincinnati")*
Please upload a .png file of your affiliated entity's logo (with transparent background). This will be used to represent your chapter on the TBTN website.*

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I have received written approval from my affiliated entity to form a TBTN Chapter. (If you select yes, you will be required to upload your verification document in this form.)*

YesNoCurrently in the approval process
If you are currently in the approval process, please explain.
Upload verification document demonstrating affiliated entity's approval of TBTN Chapter formation. For example, an email or letter of confirmation stating you have complied with your entity's group or club requirements. If not affiliated with an entity, submit Chapter bylaws.*

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Chapter Mailing Address (must be a Business Shipping Address and able to receive packages from UPS - verify your UPS shipping address here: https://www.ups.com/address_validator/search?loc=en_US)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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
Chapter Officers & Advisor
Chapter Advisor Information
- For high schools and institutions of higher education:
  - Must be a full-time paid employee of the academic institution and have appropriate approval from the institution to serve in this position.
  - Must commit to being the long-term representative and primary liaison between the Chapter and Take Back The Night.
- For all non-academic entities:
  - Must be a full-time paid employee or senior officer of the company, military base, organization, or other entity and have the appropriate approval from the entity to serve in this position.
  - Must commit to being the long-term representative and primary liaison between the Chapter and Take Back The Night.
Advisor Name

First NameLast Name
Advisor Preferred Pronouns*

She/her/hersHe/him/hisThey/them/theirsZe/zem/zirOther
Advisor's Title/Role at their Entity*

Title IX DirectorCounselorProfessor/TeacherHealth ProfessionalPrincipal/DeanDepartment DirectorDivision DirectorSupervisorHR DirectorBoard MemberSenior OfficerOwner/CEOPresidentExecutive DirectorManagerOther
Advisor Email
example@example.com
Advisor Phone (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
Advisor Office Phone (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
Chapter President Information
- Serves as the primary representative of the TBTN Chapter and the “face” of the Chapter.
- Responsible for publicly representing the Chapter to the community and to Take Back The Night.
- Makes executive decisions and distributes tasks to officers and members.
- Acts as the primary communicator between the officers and the advisor.
- Leads Chapter meetings.
- Heads year-long planning.
President Name

First NameLast Name
President Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsZe/zem/zirOther
President Email
example@example.com
President Phone (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
Chapter Vice-President Information
- Manages the members of the Chapter and maintains the Membership Roster using the TBTN Template in an Excel sheet listing each member’s first and last name, cell number, email, shirt size and whether the member has paid their $25 USD Member Dues for the year (collaborates with the Treasurer on this).
- Responsible for initiating the removal of members or other officers.
- Assists the President in leading Chapter meetings and year-long planning.
- Interfaces with vendors, donors, sponsors, and others involved in Events.
- Responsible for membership recruitment.
Vice-President Name

First NameLast Name
Vice-President Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsZe/zem/zirOther
Vice-President Email
example@example.com
Vice-President Phone (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
Chapter Treasurer Information
- Responsible for managing and documenting the finances of the Chapter.
- Collects membership dues, fundraising amounts, and donations.
- Works with TBTN regarding any local charity about funds raised on their behalf by the Chapter.
- Responsible for purchasing any other TBTN Event Gear or other items needed for Events.
Treasurer Name

First NameLast Name
Treasurer Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsZe/zem/zirOther
Treasurer Email
example@example.com
Treasurer Phone (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
Chapter Secretary Information
- Responsible for all Chapter communication, including internal and with TBTN.
- Manages social media for the Chapter.
- Leads Chapter members in creating promotional materials for Events.
- Supports the President and Vice President.
- Distributes TBTN Chapter T-shirts to members.
- Keeps all notes, minutes, and records (other than financial).
- Helps recruit members.
Secretary Name

First NameLast Name
Secretary Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsZe/zem/zirOther
Secretary Email
example@example.com
Secretary Phone (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
Chapter Members
We have at least 5 confirmed members.*

YesNo
We understand that each member must pay their membership dues of $25 USD annually to receive T-shirt and other TBTN benefits. Should members wish to join but are unable to pay the $25 fee, they may pay $15 as a membership fee, but will not receive a TBTN t-shirt.*

YesNo
Number of anticipated members (including officers)*
Number of members who would like to pay $13 to receive a discounted TBTN shirt (we will be in touch for payment and sizes)*
Constitution
You received a copy of the model TBTN Chapter Constitution upon submitting the Chapter Interest Form. After modifying it for your Chapter’s needs, upload a copy of the Constitution (signed and dated by President and Advisor) here. The file must be submitted as a .pdf file.*

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Do you have any additional questions or comments?
Benefits to being a TBTN Chapter include:

Resources
- TBTN Event Manual
- TBTN monthly Newsletter
- One hour Planning and Strategy Meeting
Gear
- Discounted TBTN short sleeve t-shirts ($13 each)
- Discounted Co-Branded Special Order t-shirts ($15 each with minimum purchase of 50)
- Eligible to receive product samples from TBTN Sponsors
- 10% Gear Discounts
- $100 discount on TBTN Event Kit of the Year
Exclusive Events
- Access to Global Virtual Events (2 a year)
- 10 seats for a pre-event Meet and Greet for Global Virtual Event
- Access to 8 Chapter Meetings a year with all TBTN Chapters per year
- Invitation to annual TBTN Leadership Rally and TBTN Institute
- 10 seats in the Dear Katie Podcast "listening booth" per year
Promotion and Marketing Support
- 3 permanent posts on TBTN's Social Media Platforms per year
- 3 (24 hour) story reposts on TBTN's Social Media Platforms per year
- Chapter listed on TBTN website
Please Read and Agree to the Following TBTN Chapter Terms and Conditions

Our Chapter along with our members and Event participants, collectively and hereinafter “CHAPTER,” agrees to the following listed terms and conditions of being a TBTN Chapter. Our CHAPTER also agrees to the terms and conditions listed on the Take Back The Night Foundation (hereinafter “TBTNF”) website, including but not limited to the Terms for holding and participating in TBTNF Events, acquiring, and using TBTNF gear, participating in TBTNF webinars or other virtual programs. All terms and conditions listed in this paragraph are collectively referred to hereinafter as the “TERMS”.

Financial Responsibility: Our CHAPTER understands TBTNF does not fund the operations of TBTN Chapters. Our CHAPTER assumes full legal and financial responsibility for our Events and activities, including but limited to any costs or legal fees incurred from holding Events.

Compliance with Laws, Ordinances and Policies: Our CHAPTER agrees to abide by and conform to all applicable policies, rules, regulations, and standards of conduct as established by the host venue, city and/or state where our CHAPTER is located and wherever our Events are held.

Intellectual Property: Our CHAPTER understands it may not use the TBTNF logo, name, or any other intellectual property in any way without express, written, prior permission from TBTNF. Out CHAPTER understands any photos, recordings, artistic works, or other intellectual property submitted to TBTNF via electronic submission, including but not limited to email, text, social media, online form, or upload to a TBTNF application; may be used by TBTNF in any manner of its choosing.

Liability and Indemnification: Our CHAPTER understands the TBTNF, its officers, employees and agents shall not be liable for any health problems, injuries or damage to any person or property arising out of or related to our CHAPTER’S operations and CHAPTER-sponsored Events. Our CHAPTER and TBTNF, including its officers, employees, and agents, agree to mutually indemnify and hold each other harmless from and against any claims, demands, actions, losses or causes of action whatsoever arising out of or related to any injury related to our CHAPTER’S operations.

Termination by TBTNF: Our CHAPTER understands the TBTNF may terminate our status as a TBTN Chapter for violating these TERMS or any reason of its sole choosing and that no refund of any donations or other monies will be made by the TBTNF.

In signing this Form, I am confirming our CHAPTER has read and agreed to these TERMS. I understand I am representing and warranting I have the legal right and ability to represent my Take Back The Night Chapter and all its members and Event participants. I further agree to review these TERMS with my Chapter’s advisor, officers, members and ensure all participants in our Chapter Events agree and abide to these TERMS.
Please read the terms and conditions above and respond below:*

I hereby agree to the TBTN Chapter Terms and Conditions.
Please sign to agree to the terms above:*

Clear
Please upload a PDF copy of the signed Terms & Agreement form. *

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Thank you for your application. We will be touch within 2-5 business days with approval and your Chapter Welcome Kit or let you know if we have additional questions or your requested Chapter name has been taken already. Thank you again for your commitment and interest in supporting survivors and ending sexual violence in all forms.
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TBTN Chapter Formation Form

Chapter Officers & Advisor

Chapter Members

Constitution