First Name:
Last Name:
Organization/Affiliation:
Address:
City:
State: Zip:

Home Phone:
Work Phone:
Fax:
E-Mail:

I want to help with the following (you can check more than one):

Write Letters to the Editor of my local newspapers

Contact Legislators and Congressional Delegates

Conduct research on a policy issue (please check the specific issue you are interested in)

      Fatherhood issues
      Healthy marriage issues
      Healthy relationship skill issues

      Positive youth development

      Responsible media issues

      Other.  Please specify 

Serve on selection committee for various awards

Assist in organizing events

Assist in fundraising

Conduct classes or workshops.  Please list areas of focus: