Event/Activity Notification

Please complete this form to tell us about an event or activity that you are planning for World Stroke Day 2011.
Submitted events will be promoted on the “Around the World” section of the World Stroke Campaign’s website, along with your contact details. If you do not wish your contact details to be public, simply leave the appropriate box unticked.

* 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:

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

Next, please describe the event or activity you are organizing around the message of World Stroke Day. *
(up to approximately 500 words)

When will your event/activity take place?

	on World Stroke Day 2011 (29 October)
	from	//2011
	to	//2011

Where will your event/activity take place (city)?