Registration Form
Give to support the LGBTQ Safe Spaces Protection Project
Safe Space Protection Survey Partner Registration
Step
1
of
2
50%
Name of Organization/Business
What type of organization do you represent?
LGBTQ-led or LGBTQ-serving non profit
LGBTQ-owned or LGBTQ-serving business
LGBTQ-led or LGBTQ-affirming house of worship
LGBTQ+ or diversity center at college or university
Informal social, political or support group for LGBTQ+ people
Location that has had LGBTQ event within last year
We are not a safe space but can promote the survey to other organizations and businesses
Other
Where is your organization located?
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Virtual location?
Yes
No
Hybrid
We can (Check all that apply):
Share information for next town hall with network
Promote the upcoming release with other organizations in your network
P
Share a press release to media contacts
Share a story about threats or violence we've experienced
Host a local event/meeting to discuss survey data
Lobby local/state elected officials
I'll help in any way I can!
Select All
We would like to talk to someone to get more information
Yes
No
Contact information
First
Last
Title
Email
Website
Phone
Newsletter reach
Facebook Profile Link
Instagram Handle
Twitter Handle
LinkedIn Profile
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