PPQ Pre-Program QuestionnaireAt 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.Please enable JavaScript in your browser to complete this form.Organization *What is the name of the organization hosting the event?Your Name: *FirstLastEmail: *Event Date: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If your event covers more than one day, please enter the LAST day.Audience: *Middle School (grades 6-8)High School (grades 9-12)College LevelStaffOtherWho will be in the audience? (Check all that apply)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: *AuditoriumGymnasiumCafeteriaOtherWhat 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 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePlease provide the physical address of the event venue for GPS purposes.Contact Name:FirstLastWho 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:FirstLastPlease 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).MessageSubmit Share this:FacebookTwitterLike this:Like Loading...