The National Runaway Safeline (NRS) appreciates your help in letting us know how many youth are being reached by the curriculum. Please complete this form after EACH activity or module you have completed with a group/class and return to NRS. Please submit this form electronically or print a demographic form from and mail or fax to National Runaway Safeline 3080 N. Lincoln Ave., Chicago, IL 60657 or fax: 773-929-5150, or email to

For any questions or technical assistance in implementing the curriculum please contact NRS' prevention specialist at 773-289-1723 or
50% of survey complete.