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*
1.
Check-In
(Required.)
First & Last Name
*
School
Email Address
*
*
2.
Due to today's program, I am more likely to ASK FIRST before engaging in sexual intimacy with a partner.
(Required.)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
*
3.
I am now more likely to STOP someone from using alcohol to sexual assault another person.
(Required.)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
*
4.
I am now more likely to tell loved ones that I am here for them if anyone ever sexually assaults them.
(Required.)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
5.
What are you going to use from today's program?
6.
How would you describe this session to someone who wasn't here?
7.
If you have a real-life, positive story around consent, asking first, intervening, supporting survivors, or the strength of a survivor that you'd like to share, do so here. This is completely optional.
Please do not feel any pressure to share.
8.
If you would like to ask Mike a question or say something to Mike, this is your space to do so (completely optional). With the volume of questions Mike receives and to best help the most people possible, Mike often answers your questions in his videos on Instagram (
www.Instagram.com/MikeRespects
) and on YouTube (
www.YouTube.com/CenterForRespect.com
).
9.
We would love to reach students even sooner. If you'd like to help us speak at your former high school, please include the name of the school, the town, the city, state, and the person at the school we should reach out to. THANKS!!
Teacher at school
School you recommend we contact:
City/Town of School
State/Province of School
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code of School
Teacher's email at the school
Teacher's phone at the school
BE SURE TO CLICK ON THE "Done - SUBMIT" BUTTON BELOW: