E-mail Address:

Phone Number:

Office/Department:

Campus Address:

Please select one of the following which best describes who will be attending this training: Choose one... Staff Faculty Graduate Student Undergraduate Student More than one of the above

How many participants will be in attendance? (Sessions will be facilitated for groups of 5-15 people)



Which date and time would you like to have this training? ( Please allow 3.5 hours for the session, which may be spread out over two days)
Date(s): Time(s):

Where will the session be held?
Building: Room #:

Does the location have the following equipment?
Computer: Choose one... Yes No
Projector: Choose one... Yes No
Dry Erase Board: Choose one... Yes No

Read before submitting form:

By submitting this form, I understand that Safe Space is a voluntary program and is not intended to be used as a required training program by my department, my supervisor, or the University.

I also understand that participants of this program will pledge to:

1. Strive toward continued development, learning, awareness, and action, and to search for further ways of understanding LGBT individuals
2. Promote an environment where members of the LGBT community do not have to censor their identities 
3. Promote an atmosphere where members of the LGBT community can participate fully, equally, and openly in campus life without fear of discrimination and/or harassment
4. Promote a safe and affirming place for LGBT people by offering an atmosphere and personal relationship of respect, fairness, and trust
5. Serve as a resource of information for students, faculty, and staff having questions about LGBT issues, and be willing to refer students to support and resources on campus and in the community
6. Maintain confidentiality