Faith-based Organization (FBO) Registration

Thank you for registering your faith-based organization to participate in the Teal Green Heart (TGH) initiative. Please complete this form below or you can email a PDF copy to [email protected]

Faith-based organization’s (FBO) information
FBO’s legal Name

FBO’s website

Faith-based organization physical address

Faith-based organization mailing address (if different)

State

Country

Organizations telephone number

Phone country code (If outside of U.S.)

Organizations administration Email

Clergy’s Email

Year FBO was established

Faith-based organization’s doctrine Affiliation

Does the organization have an existing initiative or program to help the general public with criminal challenges, sexual assault, rape?

Does Your FBO currently assist or have a program to aid any of these types of populations Pedophiles , Accused Perpetrators ,Sexual Assault Offenders that have, completed prison or jail sentence, Accused Rapist , and/or allege sexual offenders?

Does Your FBO assists and/or serve the general public?

Does Your FBO currently assist or have a program for domestic abused women, human traffic survivors, sexual assault survivors, and/or rape survivors?

Please describe the organization’s existing program (s) geared to help rape victims:

Does your organization have a private office or room available for advocates to communicate with rape or sexual assault survivors with discretion?

Is your organization open to helping male, female and/or transgender rape victims that are a part of the from the LGBTQ community?

Is your organization open to helping individuals convicted of a crime and/or accused of a sexual assault and/or rape-type criminal offenses?

Please explain why your organization desire to become an affiliate with Teal Green Heart initiative?

Does your organization currently assist sexual assault or rape survivors?

Do you encourage survivors to report the crime or offense to law enforcement?

Does your FBO currently have a policy to report sexual assault related matters, alleged crimes, and/or offenses that involve minors and FBO leaders directly to law enforcement?

Advocate #1
Information does your organization have an advocate (s) that they to recommend?

Advocate’s Title:

Advocate’s Full Name

FBO Advocate’s telephone number Complete Physical Address

Advocate’s email

Advocate #2
Depending on church size and community demographics, does your organization have a 2nd advocate to recommend?

2nd Advocate’s Title

2nd advocate’s Full Name

2nd Advocate’s telephone number

2nd Advocate’s email

Advocate #3
Depending on church size and community demographics, does your organization have a 3rd advocate to recommend?

3rd Advocate’s Title

3rd advocate’s Full Name

3rd Advocate’s telephone number

3rd Advocate’s email

To be completed by head/lead clergy person
Is your FBO aware of the teal green heart duty and commitment located the MOU? e of the Teal Green Heart Duty and Commitment?

Complete name of the Alternate location

FBO complete physical address

Country

Please provide the phone number at the Alternate meeting location (please include country code if located outside of the United States)

Clergy title

Clergy name

Clergy’s cell telephone number w/country code (if located outside of the united states)

Clergy’s Email

Name of Organization administrator referring

Organization administrator’s email

Organization administrator title

Are you an administrator at this organization?

Are You in good standing member or leader this FBO?

Which days of the week are the church or FBO doors open to the public?

Does church operate in a private home?

Do you have access to a private office at this church to meet with a rape survivor in a completely private room or office?

Does the FBO administration know that you are applying to be a Teal Green Heart advocate and/or for the FBO to partner with the TGH initiative?

How did you hear about the Teal Green Heart initiative

Are you a federal 501c3 organization?

please download letter of determination from the IRS or email a PDF copy to [email protected]
FBO’s EIN number

Recommender

I understand the purpose, responsibilities, and commitments of the teal green heart initiative as outlined as duty and commitment in the mou. I understand that an advocacy position must be fulfilled by an “become an advocate” applicant who applied for and agree to support the applicant in their efforts to meet these requirements. I also understand that the advocate is not tgh employee but a good standing member of the fbo organization. Our fbo will accept donation and provide the advocate with a private office and/or confidential closed-door room for the advocate to communicate with individuals in need of help associated with sexual assault and/or rape services.

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Please Upload Your Signature

Date [mm-dd-yyyy]

I have provided truthful and accurate information and agree to the TGH Initiative rules, regulations, and terms.