Sponsoring Organization

Name:
Street Address / PO Box:
City, State, Zip:
County:
Phone:
Fax:
Email:

Program Coordinator

Name:
Street Address / PO Box:
City, State, Zip:
County:
Phone:
Fax:
Email:

Program Information

Speaker Name:
Program Title:
Date:
Time:
Program Location:
Address:
City, State, Zip:

How did you learn about UHC's program?

How will you publicize this program?

What is the estimated size of the audience?

Application Checklist (check box for yes)

I have already confirmed with the presenter that he/she is available on the date provided above.

I agree to be responsible for facilitating this program, for filling out a program coordinator evaluation form, and for having audience members fill out audience evaluation forms.

I agree to introduce the presenter orally and credit UHC in all publicity for providing the program.

I understand I will need to document "matching" funds (cash or in-kind donations) for each dollar UHC will provide.

I understand I will receive a written confirmation if the program is approved, and I will not publicize the event until I recieve such a confirmation.

I understand UHC will not provide funds for a speaker or program title not listed on UHC's website.