Peace Learning Center Program Interest Form
RequiredRequired Question(s)
Required 1.
Contact name:
 

50 characters left.
Required 2.

Organization: 


 

50 characters left.
Required 3.

Contact phone number: 


 

50 characters left.
Required 4.

Contact email address: 

 

50 characters left.
Required 5.

Street address: 


 

50 characters left.
Required 6.

City: 


 

50 characters left.
Required 7.

State:

 

50 characters left.
Required 8.

Zip code: 

 

50 characters left.
Required 9.

Preferred method of follow-up communication: 

Phone
Email
Mail
  • Comment:

  • 500 characters left.
Required 10.

What are the issues your group is experiencing that you would like to be addressed during a potential Peace Learning Center program? 

 

350 characters left.
Required 11.

Anticipated number of participants: 

 

50 characters left.
Required 12.

Please indicate the target audience for the program: 

Preschool Children
Elementary School Children
MIddle School Youth
High School Youth
Youth-serving Professionals
Other Adults (Including College Students)
Other  
  • Comment:

  • 500 characters left.
13.

Date(s) of program (if known) and timespan: 

 

50 characters left.
14.

Budget for program (if known): 

 

50 characters left.
Required 15.

Desired goals/outcomes for the program: 

 

1000 characters left.