Please provide the following contact information:

Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone

Please read the following statement.  If your organization agrees to these terms, please enter the name and title of your organization's presiding officer.

Our organization is applying for the use of the Battered Women’s Justice Project video-conferencing room and equipment.  We have received, read, and understand the type of video-conferencing equipment and services available at BWJP, the fee structure, and conferencing procedures. 

Our organization further agrees to fully indemnify, release, discharge and hold harmless BWJP as well as its respective trustees, officials, officers, employees, servants and agents, from any and all claims, demands, causes of action and fees arising from use of our facility.  It is understood that any special use requirements necessary to comply with the law, whether ADA or other law, will be our organization’s full responsibility.  BWJP is hereby held harmless in any instance in which use of its facilities have been misrepresented and/or found to be in non-compliance with any federal, state, or local law, ordinance, order or in regard to any other liability.

We understand that by entering the name and title of our organization's presiding officer, we are agreeing to these terms in full.

Presiding officer's name
Title

Requested date for videoconference:   

Requested start time for videoconference:    (hh:mm:am/pm)

Estimated length of videoconference (in minutes):    

Number of sites (including you)? 

We would like BWJP to:

Place the call
Receive the call

Date for connectivity test:  

Contact person at your organization:

Name
Title
Work Phone
E-mail

Contact information at remote site #1:

Name
Title
Organization
Work Phone
FAX
E-mail

Contact person at remote site #2:

Name
Title
Organization
Work Phone
FAX
E-mail

Other details:

BWJP will respond to this request within 48 hours.  If you have any questions, please call Marijka Belgum-Gabbert at 612-824-8768, ext. 113.