| Prefix |
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| First Name |
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| Middle Name |
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| Last Name |
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| Suffix |
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| JobTitle |
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| Organization |
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| Street/Mailing Address 1 |
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| Street/Mailing Address 2 |
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| Street/Mailing Address 3 |
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| City |
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| State |
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| Zip |
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| Phone |
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| Fax |
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| E-mail |
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| If you have any dietary needs, please notify us of them by using the text box provided. |
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Please inform us of any other special needs you may have:
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If you need interpretation services please use the box below
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| If you have any hearing impairments, please check the box. |
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EXPERIENCE
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| Please indicate the number of years you have been working with victims of domestic violence or sexual assault |
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| Please indicate your total years of experience working with immigrant women. |
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TYPE OF FUNDING AND GRANT
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| Please indicate whether you are an OVW grantee or sub-grantee, and specify the type of OVW grant that will be funding your participation in this training. |
| Grantee/Subgrantee |
| Grantee |
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| Sub-grantee |
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| If you are a sub-grantee, please enter the name of the grantee organization with whom you are a partner on their OVW grant. |
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| Type of OVW Grant |
| Legal Assistance for Victims |
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| STOP |
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| ARREST |
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| RURAL |
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| Safe Haven Continuation |
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| OTHER OVW GRANT |
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| If you are not an OVW grantee or subgrantee, will you be requesting funding to assist you to attend this summit as part of your state team? If your answer is yes, please check the box. |
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| ORGANIZATION TYPE |
Victim Services-If yourorganization provides victim services, please specify the kind oforganization you work for from the options below.
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| Coordinating council/Task force |
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Culturally specific community programs (includes community based organizations and immigrant rightsgroups)
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| Disability/Deaf Organization |
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| Domestic violence program |
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| Elder organization staff (non-governmental) |
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| Faith-based Organization |
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| Family Justice Centers |
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| Healthcare Provider |
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| Mental Health Care Provider |
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| Multidisciplinary Group |
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| Sexual Assault Program (Staff and Boards) |
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| Social Service Organization Staff |
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| Stalking program (Board and Staff) |
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| State, Tribal or Territory Coalitions |
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| Substance Abuse |
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| Supervised Visitation/Exchange Center Assistance Providers |
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| Transitional Housing Program |
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| Tribal Sexual Assault or Domestic Violence |
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| Victim-witness Specialist |
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| Lawyers - If you are a lawyer, please specify your area of expertise from the choices below. |
| Legal Services Agency |
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| Family Lawyer |
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| Immigration Lawyer |
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| Perpetrator Attorney-Criminal |
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| Perpetrator Attorney-Civil |
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| Law Firm |
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| Language Services- If you are an interpreter, please check on the box below. |
| Interpreter (provides services to victims) |
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| University - If you work for a university, please check the box that best describes your work. |
| Campus Judicial/Disciplinary Board Members |
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| Campus Police |
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| Law Professor |
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| Law Student |
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| Student (non-law) |
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| Professor (non-law) |
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| National Organizations |
| National Technical Assistance Provider |
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| Research/Policy Institute |
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| Women's Organization |
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| Media (News) |
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| Government |
| If applicable, please select the government agency you are employed with from the choices below. |
| Adult Protective Services |
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| Child Protection Services |
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| Corrections (probation, parole, and correctional facility) |
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| Forensic Examiner Program |
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| Law Enforcement |
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| Prosecutor's Office |
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| Public Defender |
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| Tribal Government |
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| Department of Homeland Security |
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| Health and Human Services |
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| Department of Justice |
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| Department of Defense |
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| Department of Education |
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| Housing and Urban Development |
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| Department of Labor |
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| Department of Agriculture |
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| Equal Employment Opportunity Commission |
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| CONTEXT OF WORK |
| Please indicate which of the following categories best describes your work. Pick the three most relevant choices only. |
| Topics |
| Domestic Violence |
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| Sexual Assault |
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| Stalking |
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| Trafficking |
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| Crime Victim |
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| Immigrant |
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| Refugee |
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| Asylee |
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| Migrant Worker |
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