Virtual - Community Outreach

Organization Name*
ie. Organization, Club, Company etc.
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*

Company/SponsorEnewsletterFlyerFriend/FamilyPrint MediaRadioSocial MediaVoice2Change PodcastWebsiteOther
Name of friend/family member*

First NameLast Name
Name of company/sponsor*
Contact Name*

First NameLast Name
Contact Email*
example@example.com
Contact Phone *

Area CodePhone Number
Time of JDNM Presentation*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Event Name
Event Date*

MonthDayYear
Date
Event Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Type of Audience*
ie. Adults, children, mixed
Estimated Number of Attendees*
What is your budget for this presentation?*
Would you like a Q&A session?*

YesNo
Will you have a counselor available for your attendees during and immediately following our presentation should the need arise?*

YesNo
Who would you like to be responsible for video communication? (ie. zoom, webex)*

Jane Doe No MoreMy Organization
Feel free to leave any other additional information or questions.
Our Community Outreach program relies on funding from individuals, organizations, and businesses. We are happy to work with you to bring this program to your community.

We look forward to working with you.

Thank you for your interest.
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