Form Center

2. Name of Organization*
3. Point of Contact/ Email Address*
5. Point of Contact/ First Name*
6. Point of Contact/ Last Name*
7. Phone Number*
9. Address*
11. City
12. State
13. Zip Code
15. Type of Organization*

    1. Business
    2. School
    3. Place of Worship
    4. Nonprofit
    5. Other
17. CONSENT

    I have read the entire Safe Space program webpage and understand that displaying a Safe Space sticker in my organization is completely voluntary and does not create any special relationships between the City of Rohnert Park, the Rohnert Park Department of Public Safety, and my organization. In displaying the Safe Space program sticker to the public, I agree to assist those in danger of a hate crime by allowing them to enter my premises and call 911 immediately for police assistance.

19. Consent Authorization*

    1. I consent
21. DISCLAIMER

    Requesting a Safe Space sticker does not create a special relationship between the City of Rohnert Park, the Rohnert Park Department of Public Safety, and your organization, nor does it create any legal duties on behalf of the City of Rohnert Park or its entities to inspect, maintain, or manage your location or otherwise ensure that your location does not discriminate against anyone. An individual enters a Safe Space organization at their own risk. Organizations who provide a Safe Space haven to the community take responsibility for their environment. This anti-hate Safe Space program is completely voluntary for all parties involved. 

23. Disclaimer authorization*

    1. I understand
27. Signature*

    Please type your name into this box to validate the entry.

28. Date*
    Date
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field