Education & Professional Development Services Request Form

Thank you for your interest in Mazzoni Center's educational services! Please complete this form as completely as you can. One of our education specialists will reach out within 5 business days to discuss your request in more detail and start planning.

About You & Your Organization:

Question Title

* Your Information

Name

Pronouns
(ex: they, she, he)

Phone Number

Question Title

* Company/Organization Information

Name of Organization *

Address for In-Person Education *

City/Town *

State/Province *

ZIP/Postal Code *

Non-Profit
(yes or no)

Question Title

* Contact Information for Billing Purposes

Name

Pronouns
(ex: they, she, he)

Phone Number

Address for Billing

Question Title

* Which of the following best describes the industry of your participants?

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* What motivated you to make this request?

About Your Request:

Question Title

* How many people will be in attendance?

5-30

31-75

76+

Question Title

* Move the dot on the scale below to indicate your best guess of the participants' LGBTQIA competence:

Little to No LGBTQ Competence

High LGBTQ Competence

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* What is your timeline for completing this request? Please note: We require at least 6-8 weeks' lead time for customized programming.

Question Title

* Please select the service(s) that would best fit your needs:

One instructor-led training (virtual or in-person)

A series of instructor-led trainings (virtual or in-person)

A webinar or e-learning module

Consulting Session(s)

Panel coordination and facilitation

Policy review

Something else:

Question Title

* Please indicate the most accurate range for you organization's operating budget. Note: This information will be used to calculate your programming cost based on our fee structure. Further discussion to determine custom pricing for your request is welcomed.

Less than $400,000

Between $400,000 - $2 million

More than $2 million

Question Title

* Please select up to three topic areas that would be most useful and relevant to the participants:

Sex, Gender, and Sexuality 101

Pronouns

Gender-Affirming Language

Intersectionality and LGBTQIA+ Communities

Supporting Queer and Trans Youth

Supporting Queer and Trans Survivors of Sexual or Intimate Partner Violence

Queer- and Trans-Affirming Best Practices in Your Industry

Responding to Resistance to LGBTQIA-Affirming Advocacy

LGBTQIA-Affirming Workplaces

Trauma-Informed Care

Something else:

Education & Professional Development Services Request Form

Question Title

* Your Information

Question Title

* Company/Organization Information

Question Title

* Contact Information for Billing Purposes

Question Title

* Which of the following best describes the industry of your participants?

Question Title

* What motivated you to make this request?

Question Title

* How many people will be in attendance?

Question Title

* Move the dot on the scale below to indicate your best guess of the participants' LGBTQIA competence:

Question Title

* What is your timeline for completing this request? Please note: We require at least 6-8 weeks' lead time for customized programming.

Question Title

* Please select the service(s) that would best fit your needs:

Question Title

* Please indicate the most accurate range for you organization's operating budget. Note: This information will be used to calculate your programming cost based on our fee structure. Further discussion to determine custom pricing for your request is welcomed.

Question Title

* Please select up to three topic areas that would be most useful and relevant to the participants:

Question Title

* What additional information would you like us to know?