Activity Registration

Please use this form to tell us about an event or activity that you organized for World Stroke Day 2010.

We will publish your description of the activity, any attached files (documents, photos, videos), and (with your approval) your contact details in the “Around the World” section of the World Stroke Campaign’s website.  If you would prefer us not to publish your contact details, simply leave the appropriate box below unticked.

Your event or activity will also be entered for the World Stroke Awards 2010. Each entry will be assessed by a panel on the following criteria:

  • How well the activity promotes the World Stroke Day message
  • Innovation and creativity
  • Reach – did many people attend or see the activity, were local media involved, were you able to get an article in the local newspaper?
* Required Field

Please fill in the following details about yourself or your organization. Fields marked with a * are mandatory.

Surname/Family name: *
First name and middle initial: *
Title: *
Organization: *
Address: *
City: *
State:
Zip/Postal code: *
Country: *
Work phone (office hours): *
Home phone:
Fax:
E-mail address: *
Website:

Category (check all that apply) *
Individual
Scientific organization
Stroke support organization
other:
(if other, please specify:   )


I authorize the World Stroke Campaign to publish the above contact details online.

How did you hear about the World Stroke Awards? *
website
word of mouth
other:
(if other, please specify:   )


Your Activity *


Please reply to all items in this section.

What activity or activities did you organize to spread the World Stroke Day message? (check all that apply)
Educational seminars for health professionals
Educational seminars for laypeople
Advertising campaign:
  radio internet TV print outdoor advertising
Communication with government (e.g. letter writing campaign, petition, meeting)
Events (e.g. plays, walks, BP checks, risk assessments)
Stands/stalls
PR/media releases
other:
(if other, please specify:   )

When did your event/activity take place?

on World Stroke Day 2010 (29 October)
from //2010
  to //2010

Where (city, town, other location) did your event/activity take place?


Please describe your event/activity.
(Approx. 1000 words maximum; will be published online)



How did you tell people about your activity and encourage them to participate in it? (check all that apply)
local media
newsletter
poster campaign
word of mouth
other:
(if other, please specify:   )

Approximately how many people saw or attended your event/activity?


Who came to see your event/activity? (check all that apply)
stroke survivors and family
health professionals
hospital administrators
other:
(if other, please specify:   )


Did you obtain any feedback or do an evaluation of your activity, and what did it tell you?