PPNCS Tabling + Educational Session Request Form

1
What's your name?* This field is required.
First Name
Last Name
2
What's your email address?* This field is required.
example@example.com
3
Where are you located?* This field is required.PPNCS covers all of Iowa, Minnesota, Nebraska, North Dakota, and South Dakota. However, we are only able to accommodate in-person requests in the following areas due to where our staff are located. If this is a remote/virtual event, please choose "Virtual event".
Cedar Rapids, IA
Council Bluffs, IA
Des Moines, IA
Keokuk, IA
Sioux City, IA
Bemidji, MN
Duluth, MN
Mankato, MN
Rochester, MN
St. Cloud, MN
Twin Cities, MN
Willmar, MN
Omaha, NE
Lincoln, NE
Fargo, ND
Sioux Falls, SD
Virtual event
4
What is the name of the organization making this request?
5
What would you like us to do?* This field is required.Looking for a different option? You can email our Education Department (education@ppncs.org) to be directed to the best place for requests that are not tabling or educational sessions. If you would like to submit a request for both tabling and an educational presentation, you will need to submit two separate forms.
Table at an event
Single or multi-session educational presentation
6
What type of educational presentation are you looking for?If relevant, please include the age group of presentation attendees, the topic(s) you'd like covered, and any other information that might help us get a sense of what you're looking for us to provide. Topics we cover include birth control, anatomy, healthy relationships, STIs, gender and sexuality, puberty, communication, boundaries, and consent.
Huge
Large
Normal
Small
Ok
Ok
7
Would you like us to facilitate a one or two time workshop or a longer series of sessions?
One or two time workshop
Series (more than two)
8
Do you want this presentation to happen within a certain time frame? If so, when?For example: "Any Tuesday in June from 3-4pm" or "Any weekday between January and March from 12-3pm" or "Monday, August 21 from 12-2pm"
9
Where will this presentation take place?* This field is required. Please give the name of the building (if applicable) and address.
10
What is the name of the event?
11
If the event has a website, what is the URL of the website?
12
What day does this event start?
Date
Year
Month
Day
13
What day does this event end?
Date
Year
Month
Day
14
Where does this event take place?Please give the building name (if applicable) and address.
15
Is this event geared towards a specific community? If so, which community (or communities) does this event hope to reach?
16
Will PPNCS need to bring any of the following items?
Table
Chairs
Tent
Other
17
Will our table be inside or outside?
Inside
Outside
18
Is this a political or advocacy-focused event?
Yes
No
Other
19
Do you want a health educator present at the PPNCS table?
Yes
No
Other
20
Are you inviting organizations that are anti-choice to this event?For example: crisis pregnancy centers, anti-choice advocacy organizations, etc.
Yes
No
Other
21
Anything else you'd like to share?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: