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SAFE HQUSE FORM
Application for Lodging Slot
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Twitter Handle
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Your answer
Name
Your answer
Phone number
*
Your answer
Bank Account
Your answer
Bank Name
Your answer
Preferred Pronoun
Your answer
Gender
*
Woman
Man
Prefer not to say
Non-binary
Option 5
Other:
Date when slot is needed
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MM
/
DD
/
YYYY
Resident location (Include state)
*
Your answer
When are you protesting?
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MM
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DD
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YYYY
Where are you protesting?
*
Your answer
Do you have any preexisting health conditions we should be aware of?
Asthma
HIV/AIDS
STIs
Infections
Depression
Hypertension
Other:
Are there any medication, sanitary products or items (ie. Painkillers, Sanitary Pad, Tampons, Hearing aids, HIV Meds, Condoms, Charger, Whistles etc) you'll need during your stay?
Your answer
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