Youth Ambassador Activity Report

Great job on your recent Youth Ambassador presentation or activity! We love to hear about all of your hard work and awareness efforts, so after you complete your presentation please send over all of the information!

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* 1. Please enter your contact information.

Name

State/Province

Email Address

Phone Number

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* 2. Year of Youth Ambassador Training.

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* 3. Date of Activity.

Date / Time

Date

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* 4. Chapter/Support Group

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* 5. Description of Activity.

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* 6. Venue Location.

Venue Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 7. Number of Attendees.

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* 8. Comments/Special Outcomes.

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* 9. If you have any pictures of the activity, upload them here.

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* 10. If applicable, please include the link to any video, news media or article written about the activity.

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* 11. Did you distribute the community evaluations?

Yes

No

Other (please specify)