Local Chapter Planning Form

Activity Information

Title of Activity:

Proposed Date(s) of Activity:

Start Date:

MonthDayYear

End Date:

MonthDayYear

Activity Format:

Location:

Activity Overview

1. Purpose:

Please provide the overall purpose of and target audience for this<br>educational activity.

2. Objectives:

Briefly list 3-5 draft objectives for this educational activity.

Activity Contact Person

Contact Name:

First NameLast Name

Phone:

Area CodePhone Number

E-mail:

Planning Committee

Please list names and credentials of the individuals involved in the planning of this activity:

Type of Local Council Chapter Education Activity Accreditation Requested:

Are you working with an NKF office on this program?

Office Name:

Primary Contact Person: