World Elder Abuse Awareness Day Event Form

Are you holding or co-sponsoring an event or activity in observance of World Elder Abuse Awareness Day this year? If so, we are providing this form for you to share news about your event with the rest of the World! Please take a quick moment to fill out the information below. Your event will be included in a list of events in your state. Thank you for sharing your World Day event, and thank you for taking a stand against elder abuse!

1.	Contact Information:    (* = required fields) *  First Name: MI: * Last Name:   * Agency/Organization:   * City: County: * State: None Selected Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri N. Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Trust Terr Pacific Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming * Email: Web site:
2.	Event Details: * Event title:   *  Date & Time: (slowly enter numbers only    mm/dd/yyyy hh:mm.) * Location:
3.	* Type of Event (select one): None Selected Conference Contest Lecture Letter to the editor/press release Organizing a volunteer effort Press Conference Public Hearing Rally/March Senior/Disability Fair Special Newsletter Special Website Training Vigil/Moment of silence Watch Party Other
4.	Audience: Who are you targeting to participate in/attend your event? (check all that apply) General Public    All Are Welcome Seniors Adults with disabilities Intergenerational audience Children (non-school based program) Professional Groups    Banking/Financial Services Community Social Services providers (non_aging) Aging Services Providers Adult Protective Services Domestic Violence Service Providers Mental Health Services Medical/health Professionals Faith Community Law enforcement Community Legal providers/network Other Criminal Justice Professionals Local Government Community Leaders Other profession Schools    Grade School High school College Other
5.	What do you hope to achieve? (check all that apply)    Increase Public Awareness Influence Public Policy Educate/Provide Information Media Attention Other
6.    Number of participants you are planning for:
7.    Are you partnering with anyone to host/hold the event? (Y/N) Yes   No
8.    * Is this the first time you have organized a World Elder Abuse Awareness Day event? (Y/N) Yes   No
9.    Is this the first time your community has observed World Elder Abuse Awareness Day? (Y/N) Yes   No
10.	* Description of event: (max. 1500 characters) Do Not Format the text: Just start typing and continue until your description is complete; use only 1 space between sentences.
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