ProtecTeens Presentation Request Form

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Please note that fields followed by an asterisk (*) are required.

Event Coordinator Contact Information
First Name:*
Last Name:*
Organization Name:*
Daytime Phone:* example: 999-999-9999
Cell Phone Number: example: 999-999-9999
Fax Number: example: 999-999-9999
Name of the Event:*
Attendees:* (Expected number of attendees.)
Address of Event:*
State: ID
Zip Code:*
Directions to Event Location:*
Person to introduce speaker:*
Meal Charge: (Guest charge if a meal is involved.)
Please provide a brief description of your organization:*


Please provide us with three DIFFERENT preferred dates for scheduling:*
#1     Time:  
#2     Time:  
#3     Time:  



ProtecTeens Resource Kit Educational Manuals Idaho Internet Crimes Against Children Task Force Website