NIIW Activity Form

If you held or are planning an NIIW activity, we'd like to hear about it. Please complete this form and submit by clicking the "Submit Form" button.

(* indicates a required field)

Organizational 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 No

May we contact you?* Yes No