ACTIVITY REGISTRY FORM

To create a new organization listing and activity registration, please fill out the fields below. All fields are required. If you wish to update a current registration with new information please contact the Registry Administrator.

If you plan to use The Heart Truth campaign’s logo or materials and/or the Red Dress image in any form for your activities, please read the Terms of Use and The Heart Truth Logo Usage Guidelines.

Completion of this form is voluntary. Completing this form indicates your willingness to post your activity for public use. Before we can post your activity, you must identify yourself so that we can easily verify or clarify any information if necessary. The NHLBI will use your personal information only in the ways indicated in our Privacy Statement. Only activities that feature women's heart health will be accepted. Submissions that promote businesses or commercial activities or products will not be accepted.

* Indicates required field.
Please do not use the following character combinations when filling out the form:
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*Organization:
*Partner Organization:	If you worked with other organizations or groups please list them below.
*Area Served:	Please select the state your activity takes place. If this is a national level activity or if your activity serves more than one state, select NATIONAL from the pull down menu below. If other, please specify:
*Description of Organization:
ACTIVITY INFORMATION
*Activity Title:
*Activity Date:	Start Date: End Date:
*Activity Category: (select all that apply)	Educational session(s)/workshop/conference Risk factor(s) screenings Run/walk Media/advertising Educational materials dissemination Health fair Gala/luncheon/other social event Red Dress fashion show National Wear Red Day activity/event Email/newsletter promotion Blog Other Other Activity Category
Activity Description: This description will be posted on the Web exactly as you enter it. If you wish, include contact information.*
*Audience:	Please describe the specific target audience (e.g.: media, medical practitioners, etc.) for whom this activity was designed, if applicable. If other, please specify:
*Anticipated Attendance/Reach:
*Setting:	Select a description of the environment or setting in which your activity takes place. (Select all that apply) Hospital Community health center Health department Other healthcare Faith-based Media Community Work site Education Retail Other other setting
IDENTIFICATION (For verification purposes only. This information will not be published on our web site.)
*Contact Name:	Last:
*Title:
*Address 1:
Address 2:
*City:
*State:	Required for U.S., Canada, and Australia If you do not find your state in the list above, please enter it in the box below:
*ZIP/Postal code:
*Country:
*Telephone:	- - area code beginning of phoneending of phone
*Email:

*Enter 5-character verification code below into the box on the right:

code

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ACTIVITY REGISTRY FORM

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