A.J. "Keepin It Real" Johnson

Building Communities and Saving Lives

NAVIGATE:
Program Registration Form

PLEASE REGISTER YOUR REQUESTED ACTIVITY BY COMPLETING THE FORM BELOW:

A.J. "Keepin' It Real" Johnson
P.O. Box 66536
Baton Rouge, LA 70896
Call: 225-268-9336 Email: STDAIDS@aol.com

All Proceeds Support HIV Education and Prevention!  Please feel free to visit Baton Rouge AIDS Society's website and find out how your support can help prevent the spread of this deadly virus.

Baton Rouge AIDS Society
Schedule Your Program TODAY!
Please fill out the following Activity Request Form for your upcoming event:
The field marked with (*) are required fields.
* Organization Name:
* Address:
* City:
* State:
* Zip Code:
Country:
* Contact Person:
* Title of Contact:
* Day Phone:
* Night Phone:
* Email Address:
* Address of Location for Activity:
* Title of Event:
* Describe Program Focus, Purpose and/or Nature (What would you like to see happen at your program?):
* Please select the type of program that you would like to have presented at your site.
* Projected Number of Participants (How many participants do you expect to attend this event): 1 - 5
6 - 10
11 - 15
16 - 25
26 - 50
51 - 75
76 - 100
101-500
Over 500
* Gender of Participants: Male
Female
* Race of Participants: White, Non-Hispanic
Black, Non-Hispanic
Hispanic
Asian/Pacific Islander
American Indian/AK Native
Other
* Age of Participants: YOUTH (Age 24 and Younger)
ADULTS (Age 25 and Older)
* Type of Audience:
* Date of Event:
* Time the entire event Begins and Ends (Ex:10:00 am - 1:00 pm):
* What time would you like for us to begin and end our presentation (Ex: 11:00 am - 12:00 noon):
* Name of Person/Department Completing Request:
Comments