Your Full Name:
Email Address:
City/State Where Event Will Take Place:
Date of Screening (or potential dates)
I'm Hosting This Event as an:
Individual
Organization
Other
Please describe:
Name of Organization
Estimated Audience Size
Please select...
0-25
25-50
50-100
100-200
200+
Do You Need Additional Assistance or Support from Hispanic Access (Ex: flyers, promotional materials, DVD/USB with film, outreach to panelists or elected officials, etc.)
Yes
No
Please Describe:
Will You Be Holding a Discussion or Roundtable in Conjunction with the Screening?
Yes
No
Maybe
Anything Else You Would Like to Share?
Contact Information