| Name of Organization |
|
| Contact Person |
|
| Phone |
|
| Email |
|
| Target Group |
|
| Nature of the Program |
|
| Date Preferred |
ex. May 15, 2007 |
| Time Preferred |
ex. 1:00-2:30 pm |
| Length of Program Preferred |
ex. 1 hour |
| Location Preferred |
|
| Please check here if contact person is able to supply a computer and/or projector. |
|
| Approximate Number Attending |
|
| Comments and Special Instructions |
|
|
|
|
|
