NWI AHEC Teaching Resources
Request Form
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Email *
Name *
Phone Number: *
Email *
Organization *
Name of Event/Activity *
Date of Event (you may add multiple dates) *
Location of Event *
Type of Event/Activity *
Estimated number of participants?
Date item/s needed by? *
MM
/
DD
/
YYYY
Item/s to be picked up or delivered? (AHEC will contact you to arrange pick up or delivery logistics.) *
Date item/s will be ready for return? *
MM
/
DD
/
YYYY
Item/s Requested:
Select all the items you are requesting
Cancer
Dental
Disease
Drugs & Alcohol
Nutrition
Sex Education
Shaken Baby Syndrome
Smoking & Tobacco
Other
A copy of your responses will be emailed to the address you provided.
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