Screening Information Submission Form
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Thank you for choosing to screen TAKING DOWN THE WALLS! Your audience will thank you and so do we!

PER the Terms and Conditions of the TAKING DOWN THE WALLS EDUCATIONAL OR SCREENING PACKAGE USER LICENSE AGREEMENT:

Please fill in the details of your event below.

*
1. Who is hosting the event?

Who is hosting the event? Organization Name
Organization TAX ID #
Organization Website
Organization Contact
Organization Contact Phone
Organization Contact Email

*
2. What day, date and time is the event?

	MM		DD		YYYY		HH		MM	AM/PM
Date and Time Start	What day, date and time is the event? Date and Time Start Month	/	Day	/	Year		Hour	:	Minute	AM or PM
Date and Time End	Date and Time End Month	/	Day	/	Year		Hour	:	Minute	AM or PM

*
3. What is the Venue? Venue Address? Special Instructions for Parking or access?

What is the Venue? Venue Address? Special Instructions for Parking or access?

*
4. Please describe the screening event (in honor of, fundraiser, support group, continuing education...)and whether this is the first screening of AUTISTIC LICENSE for this organization~~If not, how many times has it been screened previously?

Please describe the screening event (in honor of, fundraiser, support group, continuing education...)and whether this is the first screening of AUTISTIC LICENSE for this organization~~If not, how many times has it been screened previously?

*
5. Is the screening FREE or is there a charge? If charging for tickets, at what price? If there are multiple price brackets, please list them.

Is the screening FREE or is there a charge? If charging for tickets, at what price? If there are multiple price brackets, please list them.

*
6. Number of attendees expected?

Number of attendees expected? Less than 10

10-25

26-75

76-150

151-300

301-500

501-1,000

7. RSVP info, Special Needs Assistance, Registration or Information URL

RSVP info, Special Needs Assistance, Registration or Information URL RSVP Contact
RSVP Contact Phone
RSVP Contact Name
Special Needs Assistance Contact
Special Needs Assistance Phone
Special Needs Assistance Email
REGISTRATION OR INFORMATION URL for event

8. If you are having a Post-Discussion or Workshop at your event, who are your speakers or panelists?

If you are having a Post-Discussion or Workshop at your event, who are your speakers or panelists? Name
Title
Organization
Confirmed (y/n)
Name
Title
Organization
Confirmed (y/n)
Name
Title
Organization
Confirmed (y/n)
Name
Title
Organization
Confirmed (y/n)
Name
Title
Organization
Confirmed (y/n)
Name
Title
Organization
Confirmed (y/n)

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9. If you are recruiting Sponsors or Vendors,

If you are recruiting Sponsors or Vendors, What are you charging for Sponsorships?
What are you charging for Vendor tables?

Screening Information Submission FormExit this survey

Default Section

Thank you for choosing to screen TAKING DOWN THE WALLS! Your audience will thank you and so do we! PER the Terms and Conditions of the TAKING DOWN THE WALLS EDUCATIONAL OR SCREENING PACKAGE USER LICENSE AGREEMENT:Please fill in the details of your event below.

*1. Who is hosting the event?

*2. What day, date and time is the event?

*3. What is the Venue? Venue Address? Special Instructions for Parking or access?

*4. Please describe the screening event (in honor of, fundraiser, support group, continuing education...)and whether this is the first screening of AUTISTIC LICENSE for this organization~~If not, how many times has it been screened previously?

*5. Is the screening FREE or is there a charge? If charging for tickets, at what price? If there are multiple price brackets, please list them.

*6. Number of attendees expected?