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Community Engagement Request
Thank you for completing this form to provide the best proposal for you and your organization/community. If you have any questions about completing the form, please email: MindfulMatters585@gmail.com
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Email
*
Your email
Requested Date(s) & Times for Program
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Are you flexible with day/time if this time is not available?
*
Yes
No
Possible, let's discuss.
Presentation Topic
*
Your answer
Audience
*
Your answer
Number of Attendees Expected
*
Your answer
Program/Event Address
*
Your answer
Contact Name
*
Your answer
Contact Phone
*
Your answer
Contact Email
*
Your answer
Audiovisual Support Available On-Site
*
Your answer
A copy of your responses will be emailed to the address you provided.
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