My Business/Organization Wants to be a "Safe to Say" Location!

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for helping raise awareness regarding domestic violence! Someone from our Shine the Light Planning Committee will be in touch to provide you with information/materials/training as requested.

Email *

Your name *

Agency or Organization *

Phone number *

Preferred contact method *

Phone

Required

County *

Chemung

Schuyler

Steuben

I would like the following provided to me: *

Brochures/Resources for my place of business

Training for myself and/or my employees

A presentation on domestic violence

A Facebook Live Video when materials are dropped off to me

Other:

Required

Best Day/Time for materials to be dropped off: *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Morning

Afternoon

Evening

Other:

Required

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms