Contact Information
Mailing Address

Organization's Phone #
Organization's Fax #

Facilitator Information
Name:
Email:
Phone:

A few quick questions:
When do you plan to start the Chain of Change video project?

Please give us a date when you hope to submit your completed Chain of Change video:

Write a brief paragraph on why your group wants to participate in the Chain of Change project and what you hope to accomplish through your participation.

Is there anything else you would like to add or are there any questions you have?