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Program & Workshop Request Form

Tell us what you’ve got planned:

Name *

First Name

Last Name

Email *

Phone

(###)

###

####

Company/Organization/School

Which JWI program would you like to bring to your community?

Violence Prevention Programs

Safe Smart Dating

Yes and Know

Advocacy Programs

Option 1

Option 2

Financial Literacy Programs

Option 1

Option 2

What is the purpose of your event?

What is the preferred date for this event?

MM

DD

YYYY

Alternate date(s) and time(s):

How much time will you allocate for this program?

1 to 2 hours

2 to 4 hours

4 to 6 hours

6 to 8 hours

several days

not sure yet

Will this program be presented online or in person?

online

in-person

If in person, please provide the address

(include the facility name, city, and state)

What is the scope of the event?

campus

local

state

regional

national

international

How many participants do you anticipate?

Which disciplines do you expect will be represented among the attendees?

(e.g. students, faculty, advocates, mental health professionals, parents, clergy, law enforcement, prosecutors)

Do you have funding for this program?

please provide the amount, if known

$

Do you have funds to cover:

travel

lodging

ground transportation

speaker fee

per diem

If participants will be asked to evaluate this program, will you share those evaluations with JWI?

yes

no

we won't be collecting feedback

Will you be able to provide JWI with the names and emails of participants in this program?

yes

no

Is there anything else you'd like to share about your event or your needs?

Thank you! We’ll be in touch to coordinate with you and bring this program to life in your community. If you have any questions in the meantime, please email Ariella Neckritz, JWI’s director of violence prevention and training.

JWI

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Washington, DC, 20036,

United States

(202) 857-1300 [email protected]

Hours

Mon 9am-5pm

Tue 9am-5pm

Wed 9am-5pm

Thu 9am-5pm

Fri 9am-3pm

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