Your name*:
What organization is the screening for*?
Daytime phone*:		Evening phone:
Email*:
Where will the screening(s) and dialogue(s) be held?
Name of building and/or address:
City, state, zip code:
Do you know the preferred date(s) and time(s) for your screening(s) and dialogue(s) Yes No
Screening date:		Screening time:
Screening date:		Screening time:
Which episode(s) do you want to screen and discuss?
Sickness/Wealth Place Matters Bad Sugar Becoming American Collateral Damage Paycheck Bough Breaks
How many people do you hope will come?		Is this free & open to the public?	Yes No
Can you provide audio-visual equipment?	Yes No	Can you provide refreshments?	Yes No
Can you provide a facilitator?	Yes No	Can your facilitator come to our training?	Yes No
How do you plan to promote this event?
Email Flyer Advertisement Word of Mouth Web Other (describe)
Do you need help with promotion?		Yes No
Comments/questions