National Children's Mental Health Awareness Day 2016 Pledge Form

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If you have any questions or experience any problems, please email AwarenessDay2016@vancomm.com.

Organization/Grant Program Name

Awareness Day Key Contact

Key Contact Title

Phone

Organization/Grant Program Street Address and City

Organization/Grant Program State/Territory

Zip Code

Type of Organization

Awareness Day Collaborating Organization

Corporation

Family Organization

Federal Agency

Mental Health Program

SAMHSA-Funded Grantee

Substance Abuse Prevention Program

System of Care Community

Youth Organization

Other:

We are interested in conducting and/or participating in the following Awareness Day activities and/or events:

Art Activity

Community Forum

Health Fair

National Webcast Viewing

Partnership-Driven Event

School-Based Event

Training Event

Website Promotion/Link

Other:

Did you take part in SAMHSA's "Awareness Day: What's in it for my Community?" webinar on December 16, 2015, in preparation for Awareness Day?

Yes

Clear selection

If yes, did you find the content shared to be helpful in your planning for Awareness Day?

Yes, very helpful.

Somewhat helpful.

Not helpful.

I did not participate.

Clear selection

SAMHSA is producing a webcast of the Awareness Day national event. Do you plan to use it as part of your local Awareness Day activities? If so, how?

Please briefly describe your Awareness Day plans/event.

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