Request a Site Visit

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GSA Site Visit Request Form

* Indicates required field

What is the name of your school? *

School Address *

Line 1

Line 2

City

State

Zip Code

Country

Name(s) of person(s) filling out this form, titles/positions, and contact info: *

i.e. Latreece Whitfield, GSA Network Coordinator, Latreece@kycohio.org, (614) 294-5437

What is your preferred site visit date and time? *

i.e. 12/12/13 at 2:00-3:00pm

If we can't do a site visit on your preferred date and time, what is your secondary choice for date and time? *

i.e. 12/12/13 at 2:00-3:00pm

Where does your GSA meet? *

Provide parking information for your school *

Current advisor(s) and years served: *

On average, how many students typically come to your GSA meetings? *

Does your GSA have elected officers? *

Yes No Unsure

Does your GSA have a mission statement? *

Yes No Unsure

Does your GSA have a constitution? *

Yes No Unsure

Which of the following activities applies to your GSA (Check all that apply) *

Support/discussion group Social gatherings and hanging out Campus education, activism, and campaigns

Does your GSA organize with other student groups on campus? *

Yes No Unsure

GSA Activities, Events, and Campaigns

Has your GSA organized any of the following Days of Action or events in the past year? (Check all that apply) *

Day of Silence Transgender Day of Remembrance National Coming Out Day LGBTQ History Month LGBTQ Black History Month Held 1 or more fundraisers Delivered peer education workshops (workshops for your classmates) Delivered teacher education workshops (workshops for your teachers) Conducted a school climate survey (about homophobia and transphobia in your school) Ally Week No Name Calling Week GSA Day Spirit Day None Other

If "Other" please list *

In what ways could KYC Connect help you most? *

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