SafeHomes Information Submission
Contact Person:
Agency:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone:
E-mail:
Funding Source:
Do you charge a membership fee?   No Yes   Fee: 

Is your network: (please check all that apply) 
School Based Community Based Government Based other   (please indicate)

The components of your SafeHomes Program includes(check all that apply) :
Directory Of Members
Handbook
Newsletter (please send sample)
Parent Education Workshops
Annual Evaluation
Volunteer Committee
Paid Staff    How many?

Your SafeHomes Network has been active for years.
Do you have an evaulation for your program?   Yes No
If so, how often do you evaluate it?

If possible, please send a sample of your Evaluation, Handbook and/or Newsletter to:

SafeHomes
4255 Harlem Rd.
Amherst, NY 14226

Would you like to be included in our International Directory of SafeHomes Networks?
  Yes No

Other comments: