Peers Influence Peers Registration

"Peers Influence Peers"

We are students dedicated to the prevention of drug and alcohol abuse among our peers.

Working together with The Elks National Drug Awareness Program, The NYS Cable and Public Broadcasting Industries, The Putnam Valley Central School District, the Multijurisdictional Counterdrug Task Force Training of St. Petersburg, Florida and Schools and Youth Programs across the country.

(If you experience server problems when submitting this form, please
call 888-820-4898 toll free for further assistance.)

Registration confirmation may take up to 24-48 hours.
Satellite coordinates will be emailed to you and your satellite technician (if listed) approximately 5-7 days prior to the listed broadcast date.

Please provide the following contact information: * Denotes required field

Event Information (Multiple selections allowed, hold control
key down during selections)

Events
Date(s)

Need to

Review Event Description? Visit this web site:

Estimated

Live Audience *

Estimated

Videotape Audience * (0-?)

POC Name

Title/

Position

Phone

(Commercial)*

E-mail

Technician's Name

(if different than POC).

Technician's Phone

Technician's Email

Unit/ Organization

How did you hear about this program?

Address to send support material if any available from sponsor.
(Complete only if first time or new customer):

Street address

Address (cont.)

City

State

Zip Code

Estimated

Viewing Room Capacity

Open

for Community Participation (thru coordination with you)?

Select Site Type

Additional

Comments: