To register to become a We Can! Community Site, please fill out all necessary information, and click the "submit" button at the bottom of this page. A member of the We Can! staff will review your registration information and approve you as a site. Please allow two weeks for the approval process. 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. Note that you do not need to sign up to be a Community Site to download resources from the We Can! Web site; however, you can sign up if you intend to conduct programming and may need technical assistance or support.

Once you have been approved as a We Can! community site, you may request technical assistance on conducting programming from the We Can! staff. If you provide information to us that you would like featured on the We Can! Web site and other venues, we will contact you to verify or clarify any information if necessary. The NHLBI will use your personal information only in the ways indicated in our Privacy Statement at http://www.nhlbi.nih.gov/about/privacy.htm. Submissions that promote businesses or commercial activities or products will not be accepted.

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Intended Level of Commitment

I have read and agree to the We Can!* Brand and Logo Guidelines

*Please specify your intended level of effort:
General Community Site Intensive Community Site We Can! City/County

*Indicate your type of community: If other, specify:

Contact Information

Please provide contact information.

Completing this form to list your information on the We Can! Web site is voluntary. However, before we can post your information, 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 stated in our privacy statement. View our privacy statement at http://www.nhlbi.nih.gov/about/privacy.htm

Primary Point of Contact
*First Name:
MI:
* Last Name:
Title:
*Name of Organization/Coalition:
*Mailing Address 1: (Please No P.O Boxes)
Mailing Address 2:
*City:
*State:	(Only 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:
* Phone:	Ext:
Fax:
* E-mail:

Regional Training
We Can! in Action e-newsletter
We Can! Invitation
Newspaper
Magazine
Web Search
Radio
Colleague
NHLBI Health Information Network
We Can! Partner
State Health Department
Television
Conference
Friend
We Can! Community Site
OtherPlease specify

We Can! Community Sites Resources

To assist your planning, implementation, and overall We Can! experience, please review and SELECT your preferences regarding information to receive and communications with your organization.

Permission to post your activities on the We Can! Web site - Let us know if we can share your experiences, and post your organization's name, city and state as a new We Can! Community Site.

Technical assistance from the We Can! national team - Let us know if the We Can! national team may contact you to provide technical assistance and support for your programming. Your contact information will not be used in any activities other than We Can! support and will not be shared with any outside parties. Privacy Statement

We Can! Community Site Listserv - Let us know if you would like to join a listserv that provides you with updates on We Can! program activities and offerings, important childhood obesity events, new resources for you to use and share, and funding opportunities, among other useful information. Listserv messages are sent out on a periodic basis, usually 3-4 times per month.

We Can! in Action e-Newsletter - Let us know if you would like to receive the program's quarterly e-Newsletter. The e-Newsletter includes highlights of We Can! community site and partner activities, updates on new resources, media features, and other program news. For a preview, follow this link.

We Can! Community Site Starter Kit
The Community Site Starter Kit is a useful set of materials that includes the following materials:

We Can! Community Toolkit: Energize Our Community: Toolkit for Action (this toolkit contains the We Can! Parent Curriculum)
We Can! Program Posters
We Can! Brochure
We Can! Parent Handbook: Families Finding the Balance: A Parent Handbook (one copy in English and one copy Spanish).
We Can! wristbands (two adult-size and two child-size bracelet)
Additional materials from We Can!

Please click the "Submit" button below and your form will be sent to the We Can! national team.

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.

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