ACTIVITY REGISTRY FORM

*Organization:

*Partner Organization:

*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.
National ---------------------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ---------------- American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands ----------------- Canada Mexico Central America South America Europe Asia Africa Australia/New Zealand ----------------- Other
If other, please specify:

*Description of Organization:

ACTIVITY INFORMATION

*Activity Title:

*Activity Date:

*Activity Category:
(select all that apply)

*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.
Patients/families Public Coworkers Customers Health professionals Organization members Media Other
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 This information will not be published on our web site.)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:

*Title:

*Address 1:

Address 2:

*City:

*State:

*ZIP/Postal code:

*Country:

*Telephone:

*Email: