Dear Mandela - Community Screening Survey

* 1. Please tell us your name and where your Dear Mandela screening was held.

Name:

Company:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

* 2. When did you hold your screening?

Date

MM /

DD /

YYYY

* 3. How many people attended your Dear Mandela screening?

* 4. How did the audience respond to the film?

* 5. NEXT STEPS: Did audience members resolve to take any action beyond the screening?

* 6. Any questions or comments for the Dear Mandela team?