Activity Grant - medium form

CONTACT INFORMATION

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* 1. Chapter/Section Name

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* 2. University/Institution Name

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* 3. Contact Person for Grant

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* 4. Name

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* 5. Telephone

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* 6. Email Address

ACTIVITY INFORMATION

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* 7. Activity type

Professional Development under $400 USD

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* 8. Activity Name

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* 9. Activity Dates

Start Date

Date

End Date

Date

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* 10. Activity Location

City

State

Country

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* 11. Activity Description (500 characters max)

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* 12. Expected number of participants from chapter/section

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* 13. Expected number of participants from university/community

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* 14. What are your top three goals for this activity? (500 character max)

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* 15. If you have had this event before, please tell us when, and how it went (500 character max)