Request a presentation in New York

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To request a presentation in New York, fill out the form below, print it and then fax or mail it to:

     Break the Cycle
     P.O. Box 6270, F.D.R. Station
     New York, New York 10150

Fax: 212.848.4678

Requester's Name:
School or Organization:
Address:
City and State:
Zip Code:
Phone:
Fax:
Email:

Date(s) of requested presentation:
Time/period(s) for requested presentation:
Length of presentation requested:

I would like the presentation to (check all that apply):

	address the dynamics of dating and domestic violence.
	discuss the civil and the criminal law related to domestic violence and the legal options available to young victims of dating and domestic violence.

Participants are:

Youth:
	Middle school students	9^th graders
	10^th, 11^th or 12^th graders	College students
	Other:
Adults:
	Law students	Other graduate students
	Teachers	School counselors
	School administrators	Parents
	Social service providers	Health care professionals
	Attorneys	Law enforcement
	Mental health professionals	Other:

Is this presentation part of a larger event? Yes No
If so, please describe:

Although all Break the Cycle's programs are offered free of charge, we depend on the community for support. To cover our time, travel and materials costs, we ask for-profit organizations (including private schools), if they are able, to reimburse Break the Cycle with a minimum donation of $100 per presentation.

Will you be able to reimburse Break the Cycle for these costs?
Yes No

Parking information or directions: