Primary Contact Name *

First Name

Last Name

Primary Contact Phone

(###)

###

####

Contact to Receive Materials (if different from above)

First Name

Last Name

Address for Materials *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Engagement (check all that apply) *

Utilizing Box of Materials (helmet stickers, hair ties, etc.)

Showing Mental Health PSA at Halftime

3 in the 3rd

Social Media Promotion

Other H3H Programs (Tyler Talk/Game Plan, Online Mental Health Course)

Media Contact

First Name

Last Name