Pathway to Prevention Program Request Form, Fall 2020

Current Prevention and Education Programs

Pathway to Prevention program options are limited during COVID 19 to prioritize the health and safety of participants and staff. In lieu of in our regular range of program options, we are offering a virtual version of our Knowledge Is Power: Sexual Assault Awareness program, which provides education on changing the culture around sexual violence and supporting survivors. Please take a moment to tell us about your interest in our programming, and we'll be in touch shortly!

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* 1. Address

Name *

Organization Affiliation

Address

City/Town *

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

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* 2. Please select the age of potential participants for this program:

0-9

10-13

14-18

19-25

26-39

40-59

60 or Over

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* 3. Please select how you would like to receive information about our Knowledge Is Power: Sexual Assault Awareness program for community and school settings.

Receive information about this program via email

Book this program (Please provide dates in the comment section)

Discuss this program with a staff member by phone

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* 4. Please note any questions you might have about our programming:

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* 5. If you would like to book a program for a specific date (or date range), please list the date(s) and time(s) here:

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* 6. Please share anything else you would like us to know about how we can meet your needs.

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* 7. Please indicate which of the following best describes your company/organization:

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* 8. What is your job title or role?

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* 9. Where did you hear about The Blue Bench Prevention and Education programs?

Thank you for your interest in The Blue Bench's Pathway to Prevention. We look forward to partnering with your organization to prevent sexual violence!