PPQ

Pre-Program Questionnaire

At least two weeks prior to Jeff Yalden’s visit, please take a little time to fill out this form in order to provide a meaningful, memorable event.

Organization *

What is the name of the organization hosting the event?

Your Name: *

First

Last

Email: *

Event Date: *//

If your event covers more than one day, please enter the LAST day.

Other Audience Type:

If you answered "other", please describe who will be in the audience.

Audience Size *

Please enter the approximate number of people expected in the audience.

Venue: *

Please provide the name of the venue (ie - school, convention center, etc).

Venue Setting: *

Auditorium
Gymnasium
Cafeteria
Other

What venue will be used for the event?

Other Setting Type:

If you answered "other", please describe what type of venue will be used for the event.

Venue Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Please provide the physical address of the event venue for GPS purposes.

Contact Name:

First

Last

Who will be Jeff Yalden's main contact during his visit? If YOU are the main contact, you do not have to populate this field.

Title: *

Please provide the title of the main contact (ie - parent, counselor, teacher, assistant principal, etc).

Email:

If YOU are the main contact, you do not have to populate this field.

Phone: *

Please provide the cell phone number of the main contact.

Principal:

First

Last

Please provide the name of the school principal or event supervisor (if applicable).

Email:

Please provide the principal's or supervisor's email.

Phone:

Please provide the principal's or supervisor's phone number.

Event Theme: *

What is the main theme of your event? What topic(s) should Jeff Yalden address?

Challenges:

Are there any current challenges/problems about which the community is concerned? If so, please describe above.

Achievements:

Are there any current achievements about which the community is proud? If so, please describe above.

Additional:

Please include any other relevant information that you would like to share.

File Upload:

Click or drag a file to this area to upload.

Please upload any documents you have regarding the event (if applicable).

Phone

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Pre-Program Questionnaire

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