SSP Interest Form

Thank you for your interest in bringing Send Silence Packing® to your campus or community! This program visits 15-30 communities per semester and we begin reviewing applications 6-8 months in advance. Please read hosting information carefully before submitting this form.

Please Note: Submitting this Host Application DOES NOT guarantee you a spot on an upcoming tour. This application allows Active Minds the opportunity to learn more about your campus or community as a potential host site. Please complete each section in full to give us the best picture of your potential as a host.

First Name

Last Name

What is your title/role at your organization?

Phone Number

Email

School (No Abbreviations)/ Organization Name

School/Organization Mailing Street

School/Organization City

School/Organization State

Zip Code

Are you an Active Minds chapter member or advisor?

YesNoNo, but I would like to collaborate with an Active Minds chapterNo, but I am interested in starting a chapter

Program Impact

Please describe the need for Send Silence Packing in your community and the likely outcomes of an exhibit.

Would you also be interested in booking a Speaking Event?

Billing and Contracting

Billing Contact First Name

Billing Contact Last Name

Billing Contact Title/Role

Billing Contact Email

K-8	High School
College/University	Professional/Corporation
Foundation	Nonprofit/NGO
Goverment/Military	Healthcare or treatment center
School System/District

January	February	March
April	May	June
July	August	September
October	November	December

Program Impact

Billing and Contracting

Planning and Logistics