NIIW Activity Form

If you are planning an NIIW 2012 activity, large or small, we would like to hear from you! Please complete this form and submit by clicking the "Submit Form" button.

(* indicates a required field)

Organization Name:

Contact:

Title:

Address:

City/State/Zip:

Phone:

Fax:

E-mail:*

Web Address:

Name of Activity:

Date of Activity:

Time of Activity:

Target Audience:

Type of Activity:

Activity Description:

Community Partner Listing:

Evaluation and/or Follow-up Plans:

May we post your city and activity description on the NIIW website?*

Yes

May we contact you?*

Yes

Security Question:*
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