General Community Site Activity Form

Please review the activities suggested below, fill out all necessary information, and click the "submit" button at the bottom of this page. If you prefer to fax your information, please download and print a PDF Version of this form and fax a completed form to the NHLBI Health Information Center at (240) 629-3246.

Contact Information

Please provide the same email address that you have used on your Sign-Up Form. Failure to specify the same email address will prevent us from being able to process your information.

If you have not signed up yet, please do so by filling out the We Can! Sign-Up Form.

Completing this form to list your activity description on this Web site, with other We Can! activities, is voluntary. The NHLBI will use your personal information only in the ways stated in our privacy statement. View our privacy statement at http://www.nhlbi.nih.gov/about/privacy.htm

* E-mail:

Program Selection

General Community Sites around the country are participating by completing two of the following three programs or events in one year.

Activity 1) One We Can! youth program/curricula**

Activity 2) One We Can! parent program/curriculum

Activity 3) One We Can! community-outreach event

**Some of the youth curricula are copyrighted and have an associated cost.

Activity 1) Complete one We Can! youth program/curricula
Please check the box next to the curriculum you will use, and complete the corresponding form below. (View curricula descriptions and ordering information on the We Can! Get Involved web page at http://wecan.nhlbi.nih.gov/get-involved/materials.htm)

Activity 2) Complete one We Can! parent program/curriculum
If plan to implement the parent curriculum, please check the box and complete the corresponding form below.

Activity 3) Host one We Can! community-outreach event

Please check the box below if you will host a will host a We Can! community event and complete the corresponding form below.

Event Name:
Anticipated event date(s):
Start Date (mm/dd/yyyy):
End Date (mm/dd/yyyy):
Kind of event
Location of the event
Description of the event
Who is the event's target audience?
How many people do you anticipate will attend this event?
What are the anticipated giveaways and incentives?
Other information you would like to include:

Thank you for selecting your activities.

Summary Form

We recommend that all We Can! community sites take up to one year to plan programs, implement chosen curricula, and conduct community events. We ask all sites then to return to the We Can! Web site to share their experiences through the We Can! Community Site Summary Form. The summary form can be downloaded from the We Can! Web site at http://wecan.nhlbi.nih.gov/downloads/summary-form.pdf. Please insert the date you plan to finish your programming here:

Estimated Program Completion Date (mm/dd/yyyy):

You have now completed your We Can Activity Form! Thank you for your interest in We Can! Please click on the "Submit" button below and your form will be sent to We Can! national organizers. If you have any questions regarding this process, please contact the NHLBI Health Information Center by e-mail at nhlbiinfo@nhlbi.nih.gov or by phone at 301-592-8573; TTY: 240-629-3255; or toll-free at 1-866-35-WECAN.