Community Partner Sign-up

Only organizations in the Philadelphia area will be eligible to be Blueprint Campaign Partners.

Yes, my organization and I want to become community partners with the Blueprint for a Safer Philadelphia Campaign. Please add me to the mailing and email list.
Please verify your contact information below and submit this form by clicking on the Process Registration Form button.

*Fields marked with are required**
Organization*	Job Title*

First Name*	Last Name*

Address*	Address 2

City*	State*

Zip Code*

Work Phone	Work Fax

E-mail *	Organization Web Site

What types of services do you provide?
	After School Program	Mentoring
	Alcohol Abuse Prevention	Nutrition
	Child Abuse Prevention	Parenting
	Computer Training	Peer Education
	Criminal Justice	Performing Arts
	Domestic Abuse	Physical Disabilities
	Drug Abuse Prevention	Pregnancy Prevention
	Employment Assistance	Prevention
	Gun Violence Prevention	Sexual Assault Prevention
	Health	Sexually Transmitted Disease Prevention/Treatment
	HIV/AIDS Related	Smoking Prevention
	Homeless	Sports and Recreation
	Housing	Support Group
	Internet	Technical Assistance
	Learning Disabilities Assistance	Treatment
	Mental Health	Violence Prevention

What MEE services and campaign activities would be of interest to you?
	HIV/AIDS Campaigns	Sexual Health Issues
	Focus Groups	Workshops/Trainings
	Violence Prevention	Smoking Prevention
	Drug / Substance Abuse	Entertainment Campaigns

Who do you serve?
	Youth / Teens	Adults
	Homosexuals	Seniors
	African Americans	Transgenders
	Latinos / as	Caucasians
	MSMs	Native Americans
	Asians	Bisexuals

Brief description of what your organization does.

Community Partner Sign-up

What types of services do you provide?

What MEE services and campaign activities would be of interest to you?

Who do you serve?

Brief description of what your organization does.