Request for Outreach and Education from Rape Crisis Center

Event Name
Event Date & Start Time

MonthDayYearHourMinutesAM/PM Option
Please describe the event and its intended audience (number, age, gender, etc.).
During what time range does an RCC representative need to be present?
If you are requesting an advocate/emotional support person, will there be a private space available for individuals to receive support?

YesNo
Will a table and chairs be provided?

YesNo
Will RCC have to pay to appear at this event?

YesNo

Please select the type of class you would like:

Private workshop ($150 per hr/$100 per hr nonprofit)Full 12-hour course ($1500/$1000 nonprofit)
Specify Desired Class Length (in hours, round up to nearest half-hour):
Please list any specific focuses or areas of interest you want us to cover:
Chimera requires room for participants to move freely, and to yell without disturbing or alarming anyone. Please choose the appropriate option:

I have secured an appropriate space.I will be able to procure an appropriate space.I will not be able to procure an appropriate space. Please contact me.
Describe the intended audience (number, age range, etc.)
Will the class be open to all genders?

YesNo - Self-identified women only.
Setting up a Chimera Self-Defense class requires signing a contract and putting down a 30% deposit ahead of time. Participants may additionally be required to sign individual liability waivers before class begins.

I understand.
How did you hear about Chimera Self-Defense?
Please provide your top three choices for the date and time of this workshop.
1st Choice:

MonthDayYearHourMinutesAM/PM Option
2nd Choice:

MonthDayYearHourMinutesAM/PM Option
3rd Choice:

MonthDayYearHourMinutesAM/PM Option
Provide any additional scheduling concerns or general notes.

When would you like to schedule a Safer Bar training? Please describe what times of day, days of the week, and month(s) would work best for you and your staff.
I understand that at least 80% of my staff must attend the training in order to receive a formal Safer Bar certification.
I understand that a Safer Bar training must take place in the trainees' actual work environment.
I understand that the trainees will need to break out into two groups, and I will provide separate spaces.
For no additional charge, RCC will work with you to develop customized best-practice policies for your establishment. Are you interested in this option?

YesNo
About how many staff members will attend this training?
Please select the most appropriate option:

My establishment is able to pay the training fee.My establishment is able to pay part of the training fee.My establishment cannot pay the training fee. Please contact me.
How did you hear about Safer Bar?
Tell us why you are interested in a Safer Bar training for your staff.
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Request for Education & Outreach from RCC: Sexual Violence Resource Center