Your Full Name *

First Name

Last Name

Phone Number *

Country

(###)

###

####

Shipping Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Screening Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Desired Format *

DVD

Digital

Anticipated Screening Date

MM

DD

YYYY

Type of Organization Hosting the Screening: *

High School/Public Library/Community Health Leader

Colleges/Universities/Non-profit Organizations

Businesses

Charging Admission *

Yes

No

Number of Screening Locations *

One

Multiple

Anticipated Audience Size *

1-250 people

Greater than 250 people