Community Education Program Request

Please use the form below to request information about or Community Education Program.

FIELDS MARKED WITH * ARE REQUIRED!

Name:*

(First)

(Last)

E-Mail Address:*

Organization:

Contact Phone:*

########## all 10 digits without () or -

Requested Date for Presentation:

Requested Time for Presentation:

Location:

Topics to be covered:

Special Requests:

Faith House Mission Statement: To provide safety, shelter, empowerment, and advocacy, to survivors of domestic violence.

P. O. Box 93145 Lafayette, LA 70509 (337)232-8954

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