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Black History Month Submission Form

Use separate form for each program/event & each date
Deadline Date: December 6, 2013
All fields with * are required

Program Information

 (mm/dd/yyyy)

 (hh:mm am/pm)

Type of Program (please check most appropriate): *







Targeted Participants:


Personal Information

In case questions arise regarding this submission:

[For Consistency, it is suggested that one person serve as contact for each department or organization]

 (XXX - XXX - XXXX)

Contact person / info to be listed publicly on poster/news release (if different from above):

 (XXX - XXX - XXXX)