Stats & Facts Form

Your outreach efforts are greatly appreciated. We'd like the opportunity to thank you with a gift. Please provide the following information:

*Please fill out required fields.

*Your Name:

*Email Address:

US Mail Address:
*Street:
*City:
*State: *Zip Code:

*Area Code: *Phone Number:

How did you find out about the RN Ambassador Program?

Describe your Presentation.
Which presentation tool(s) did you use?
(you must check at least one)

elementary	middle school
high school/young adult	none
other (please describe)

On what date did you give your presentation? (mm/dd/yy)
/ /

Location Name:

Location Type:

Location Type other than listed above?

Location Zip Code:

Describe your audience:
*How many young people attended:

*Please tell us the ethnic makeup in approximate percentages.
This information is required by our sponsors.
% African American
% Hispanic
% Asian
% Caucasian
% Native American

What age group was your audience?

Your feedback will help us improve this program.

We hope you enjoyed your experience as an Ambassador for Nursing. We thank you enormously!