Kind Hearted Woman Screener & Speaker Requests

Kind Hearted Woman Screener Request Form

Kind Hearted Woman - Screener
You can pre-order a shortened version of Kind Hearted Woman for your community engagement events and screenings. You will receive 3 copies of screeners, one for your event and two additional copies to prepare your panelists, speakers or organizations in advance of the screening.

Please allow 2 weeks to receive your screeners.

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The following questionnaire must be completed in full in order to receive your screening resources.

Q.1

Organization or Station Name *

Q.2

Contact Name *

First Name

Last Name

Q.3

Title *

Q.4

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Q.5

Phone Number *

(e.g. 1 201-234-5678)

Q.6

Email Address *

(e.g. john@example.com)

Kind Hearted Woman: Community Engagement

Q.7

Proposed Event Date *

MM
/

DD
/

YYYY

H
:

Mins

Q.8

Event Address *

Address Line 1

Address Line 2

City

State

Q.9

List proposed community partners/organizations supporting the event: *

(i.e. domestic violence and/or child abuse agencies, Native American organizations, RAINN, etc)

Q.10

Tell us about your event, what is your goal? *

Q.11

How do you plan to connect this event to the Women and Girls Lead Campaign? *