Contact Name for Event:
E-mail:
Name of Organization:
Phone:
Cell Phone:
County of Event:
Requested Dates For a Survivor:
Is This a Tentative of a Firm Date?:
Description of Event (Please let us know what type of event this will be-such as a Health Fair, a school presentation, a Youth Rally, etc...)
Projected Setting for the Event: Classroom

Gym

Auditorium

Outside Setting
Physical Address for Event:
Estimated number of youth/college students that will be in attendance:
Estimated number of adults/faculty that will be in attendance:
Estimated number of presentations that survivors will be giving:
Are your requesting a specific Survivor to participate in your event? If so, whom?
Are there any other organization contributing funds for this event?
If you are unable to be present during the event, will you provide the contact information for the attending adults/faculty who will be providing follow-up evaluation information:

 

***It is the desire of SAVE to coordinate all Survivors presentation through the office, in order to budget and plan efficiently.

 

 


***Presentation Forms are also available in PDF, Word Document and JPEG format.