Region Application

Note: Fields marked with * are required

Region *

Please answer the following questions for the organization who would provide oversight of the Bridging the Gap mobile app for your region:

Your Name *

Title *

Your Email *

Phone *

Website ( Please include http or https )*

Date founded *

501c3 ? *

EIN/Tax ID# *

Supervisor or Board Chair Name *

Supervisor Name *

Supervisor's Title *

Supervisor's Email *

Supervisor's Phone *

Organization mission/vision *

Services provided for sexually exploited or trafficked victims AND ages served

Current collaboration, coalition, or other community partners

Does your organization follow trauma informed and multidisciplinary standards of care for victims? If yes, please explain

What training does your organization require for staff, exployees, and volunteers working with survivors?

Additional information helpful to the Bridging the Gap community

Please list referrals from two established organizations or agencies affiliations

Organization name *

Contact name *

Email *

Phone *

Organization name *

Contact name *

Email *

Phone *

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