Form Submission for the

Pride Rocks! Resource Card

The Pride Rocks! Resource Card

NCCJ will print and distribute 2,500 resource cards with LGBTQ+ community resources. These cards are distributed throughout the Dayton community. Complete the below form to be featured on the card.

Please Note: After registration, NCCJ will contact your business to confirm your information and ask questions about your inclusive practices. Completion of this form does not guarantee your inclusion on the card.

Timeline:

April 12, 2024: Applications for the Resource Card are due

Prior to April 12, 2024: NCCJ will call your organization to confirm information. If you do not pick up the call, please call us back within a week of the time we leave a message. (NCCJ will likely call your business within 1-3 days of you completing this application)

May 18, 2024: The resource cards are brought to Pride Rocks! and distribution begins

Thank you for all you do for the community!

Please Note:

NCCJ publishes this resource card on half page rack cards. Due to the limited space on these cards, every submission may not be included on the print version. NCCJ will give priority to those providing mental health treatment services, and then will fill in spaces. Services that are not included on the printed cards may be included on the website version.

Pride Rocks! Resource Card Registration

2024 LGBTQ+ Provider List

Organization Name(Required)

This information will be published exactly as it written in this box

Organization Contact Person Name(Required)

This person will be called prior to the printing of the resource list to verify the accuracy of the information and to ask questions regarding the organizations efforts to be inclusive. This will NOT be published.

First Last

Contact Person Email(Required)

This information will NOT be published and is provided in the case that NCCJ needs to contact you regarding this listing.

Enter Email Confirm Email

Contact Person Phone(Required)

This information will NOT be published and is provided for NCCJ to contact you prior to publishing the listing.

Organization Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization website(Required)

This information will be published

Organization Phone Number(Required)

This information will be published

Please describe what your organization does to provide safe, affirming care to members of the LGBTQ+ community (including training, organizational practices, policies, etc.)(Required)

In one sentence, please describe the services your organization provides(Required)

This information will be published as it is written. If your organization has several separate services (for example a housing program, and a mental heath program), please fill out a form entry for each distinct service.

Select the category that best aligns to your organization:(Required)

How does your organization contribute to suicide prevention and mental wellness?(Required)

Entry to this form is FREE, however donations allow us to print additional resources and share this information further.(Required)

Selecting "Free Entry" below has no impact on the order your organization will appear on this document or the approval of your application. Donations below are to support the distribution of resource cards and will not effect your organizations entry.

Free Entry

$10 Donation

$25 Donation

$100 Donation

$250 Donation

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Phone

This field is for validation purposes and should be left unchanged.