Response FormPlease enable JavaScript in your browser to complete this form.Name *FirstLastOrganization NameAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone NumberEmail *I want to learn more about… *Hosting a training in my homeHosting a training in my churchHosting a training for my groupInviting an Empower the Fight speakerBecoming an Empower the Fight trainer in my communityOtherPlease select all that apply.Other Info Desired: *Host Training Request Details:I would Like to Host the Training *Within 30 daysWithin 3 MonthsWithin 6 MonthsSometime this YearOtherOther Time Desired *Request a Specific TrainerTraining Desired *Safe Adult Solution to Stop Child Exploitation (Introductory – 1hr)Watchful Eyes to Stop Child Exploitation (Basic – 4hr)Watch Assessment Tool for Children’s Safety (Advanced – 2hr)Steps to An Open Heart Relationship (Basic 2hr)Calm Deescalation Training (3 hr)Tenacious Teachers Advanced Training (6 hr)OtherSelect All that ApplyOther Training Desired *Number of Trainees Attending Selected Value: 0 Estimated count if possibleTrainer Information Request:Nearest Major City/Metro Area *Empower The Fight Guest Speaker Request:Date / Time Needed *DateTimeName & Location of Venue *Please describe your venue, event, meeting or session you are requesting a guest speaker for.Length Requested *– Select One –15 Minutes30 Minutes1 Hour3 HoursHalf Day EventFull Day EventMulti Day EventPlease provide the length of the speaker’s time needed.Event / Org WebsiteEstimated Audience Selected Value: 0 Gifts-N-Kind Submission:What would you like to donate? *Please provide as much detail of the item, quantity and condition that you would like to donate.Timeline I Would Like to Donate: *Within 2 WeeksWithin 30 daysWithin 3 MonthsWithin 6 MonthsSometime this YearI Would Like to Submit Via: *Attach E-Certificates/Vouchers/etcMail/Ship to 10.18 OfficeDrop Off with 10.18 RepHave a 10.18 Rep PickupSponsorship Request:Sponsorship Type– Select One –Church – Annual (Custom Payout Schedule Available)Church – EventChurch – One TimeCorporate – EventCorporate – Annual (Custom Payout Schedule Available)Corporate – One TimeCustom Plan Arranged with 10.18Event Sponsorship *– Select One –Awareness EventChristmas DriveCommunity OutreachFundraiser or GalaPlease select your most preferred type of event to sponsor. Custom Sponsorship Desired: *Please provide as much detail to the type of sponsorship you are desiring for your organization or group. If you have a specific goal in mind please let us know!File Upload Click or drag files to this area to upload. You can upload up to 3 files. Question/Comment:Submit
