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Request for Presentation (RFP) Application Form
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Download the PDF format
file of this form by
CLICKING HERE (PDF)
Or download the MS Word
format file of this form by
CLICKING HERE (DOC) |
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Form to request on-site presentation but BiasHELP educator at your school, office or group. Presentations include defining bias/hate crimes, the effects of bias on an individual and community, hate/bias crime legislation and its importance, bias crime offenders and penalization, the continuum of prejudicial behavior, bias awareness through personal inventory, Youth violence, Gangs activities, Bullying, and interactive diversity/sensitivity exercises. The presentations last approximately 90 minutes, not including discussion period. An overhead projector and microphone (depending on audience size) is needed for the presentation.
Requests must be submitted two weeks prior to date of presentation. |
 BiasHELP of Long Island
60 Adams Avenue, Hauppauge, NY 11746
(631) 479-6015 Fax: (631) 656-7241
Education Department
REQUEST FOR PRESENTATION
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Today's Date: |
____________________________________________________ |
Name of
Organization/Agency: |
____________________________________________________ |
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Mailing Address: |
____________________________________________________ |
Name of Authorized
Contact Person: |
____________________________________________________ |
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Position/Title: |
______________________
Telephone: (______ ) ____-_____ |
Presentations include defining bias/hate crimes, the effects of bias on an individual and community, hate/bias crime legislation and its importance, bias crime offenders and penalization, the continuum of prejudicial behavior, bias awareness through personal inventory, Youth violence, Gangs activities, Bullying, and interactive diversity/sensitivity exercises. The presentations last approximately 90 minutes, not including discussion period. An overhead projector and microphone (depending on audience size) is needed for the presentation. Requests must be submitted two weeks prior to date of presentation. |
Indicate specific focus, topic or
requirement(s) for this program: |
_______________________________________________ |
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Size and description of audience: |
_______________________________________________ |
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Address where program will be held:
(if different from above) |
_______________________________________________
_______________________________________________ |
Indicate both date & time of program:
Please attach itinerary |
1st Choice: Date:________ Time In:_______ Time Out:______ |
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2nd Choice: Date:________ Time In:______ Time Out:______ |
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Phone # in the event
of an emergency |
(_ _ _ ) _ _ _ - _ _ _ _ / (_ _ _) _ _ _ - _ _ _ _ |
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Check preferred format
for this presentation |
__Workshop __Lecture __In-Service __Series (of programs) |
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| BiasHELP AGENCY USE ONLY |
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Approved By: |
_________________________________________________________ |
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Date / Time of Presentation: |
____/____/____ @ ____:____ to____:____ |
Travel Time
____:____ to____:____
____:____ to____:____ |
Person(s) assigned
to program: |
__________________________________ |
| Honorarium: |
Date Received: ____/____/____ Amount: ___________ |
| Confirmation date: |
____/____/____ |
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BiasHELP EDUCATIONAL PROGRAM/LITERATURE CONSENT FORM
Acting on behalf of my organization, I have requested an education program and/or written materials from BiasHELP of Long Island. I consent to the inclusion of the following exercises in this presentation. By checking "Any/All of the above", you enable the facilitators to choose a program that best suits your audience. For a description of these exercises, please call Loida or Libny at (631) 479-6015. |
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_____ New York State Hate Crimes Law
_____ Perpetrators of Hate Crimes
_____ Community Effects of Hate Crimes
_____ Penalization of Bias Crimes
_____ The Continuum of Prejudicial Behavior
_____ Cultural Diversity
_____ Dangers & Consequences of Intolerance
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_____ National Hate Crimes Legislation
_____ Individual Psychological Effects of Hate Crimes
_____ Stereotypes
_____ Here I Stand Statements
_____ Beware of the Polarized Stereotype
_____ Everyone Has a Culture
_____ Youth Violence/Gangs Activity/Bullying
_____ Any/All of the Above
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- I agree to the distribution of BiasHELP of Long Island literature.
- I understand that I may not videotape or audiotape any speaker without prior written permission from BiasHELP.
- I agree to the distribution of an anonymous, attitudinal survey about Internet usage.
- I agree to explain and enforce (to the best of my ability or with the help of others) BiasHELP's expectation of the faculty/staff present to:
- Provide organizational or disciplinary assistance if necessary.
- Model respectful demeanor, refraining from espousing personal opinions during the workshop that might be rude, pejorative or otherwise inflammatory.
- I understand that staff/faculty may be given the choice to fully participate in conversation, debate, or other activities to the extent which it will benefit them and/or the workshop. If this is not the case, however, they will be asked to excuse themselves or to unobtrusively observe.
Checks can be made payable to BiasHELP, Inc.
Please indicate date of presentation on check.
Thank you for your help and generosity.
Tear off bottom portion and mail to:
BiasHELP of Long Island / 60 Adams Avenue / Hauppauge, NY 11788
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Honorarium: BiasHELP relies in part on honorariums and donations to underwrite our
educational programs. Please select an amount below:
___$500 ___$1000 ___$1500 ___Additional Honorarium ($__________)
______________________________________________________________________
Name & Signature of Authorized Organization/Agency Representative Date
______________________________________________________________________
Organization/Agency Name
______________________________________________________________________
Position/Title
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Download the PDF format file of this form by
CLICKING HERE (PDF)
Or download the MS Word format file of this form by
CLICKING HERE (DOC)
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