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Hip Hop Public Health – Ambassador Submission
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Please complete all required fields (*)
User name
*
First name
*
Last name
*
Password
*
Email
*
Name of your organization
*
Title within your organization
*
Nature of business at your organization
*
What is your profession
*
Phone
*
Best number to contact you.
Address
Street address
*
State (XX)
*
City
*
Zipcode (XXXXX)
*
Have you ever been arrested for any crime?
Choose response
*
Yes
No
If yes, please disclose the nature of the crime.
Have you ever been convicted of a misdemeanor?
Choose response
*
Yes
No
If yes, please disclose the date and nature of this misdemeanor.
Have you ever been convicted of a felony?
Choose response
*
Yes
No
If yes, please disclose the date and nature of this felony.
Which Hip Hop Public Health educational topics are you interested in?
Topics
*
Please select all that apply.
Nutrition: Hip Hop HEALS
Physical Activity: Hip Hop FEET and HYPE BreaksOption 2
Stroke: Hip Hop Stroke
Alzheimer's: Old SCHOOL Hip Hop
Just the nutrition and physical activity materials.
All of the above
Other
Other Topic interested in.
Only fill in if above selected as other.
Which multimedia materials do you plan to use?
Materials
*
Please check all that apply.
HHPH Animated Cartoons
HHPH Comic Books
HHPH Video Games
HHPH Music
HHPH Live Music Videos
Other
Other Materials interested in
Only fill in if above selected as other.
How many times or at how many sessions do you plan show the materials to children?
Number of times/sessions
*
1-5
6-10
11-20
21-30
31-50
More than 50
How many children do you plan to deliver the materials to at each session?
Number of Children
*
Less than 10
11-25
26-50
51-100
More than 100
Other
Other number of children
Only fill in if above selected as other.
Over what period of time do you plan to use our materials?
Period of time
*
Just one time
Over the course of 1 month
Over the course of 3 months
Over the course of 6 months
Over the next school year
I plan to use the materials indefinitely, as long as they are available to me.
Other
Other time period
Only fill in if above selected as other.
What is the age range of the children you plan to deliver the HHPH materials to?
Age ranges
*
Please check all that apply.
Younger than 5
6-7
8-12
13-17
18 and older
What is the prominent race/ethnicity of the children you plan to reach with the HHPH materials?
Prominent race/ethnicity
*
Black/African American
Hispanic
Asian
Pacific Islander
Native American
White/Caucasian
Other
Other Ethnicity
Only fill in if above selected as other.
In what type of community do you plan to deliver the materials?
Community
*
Please choose all that apply.
Urban
Suburban
Rural
In what zip code(s) do you plan to deliver the HHPH materials?
*
Please include all that apply.
Where do you plan to reach children with the HHPH materials?
Places
*
School
After School
Faith-based organization, such as a church or synagogue.
Community-based organization (such as a YMCA, Girl Scouts, or Big Brothers Big Sisters)
Day Care
Summer Camp
Hospital/Healthcare Setting
I don't know yet.
Other
Other places
Please choose all that apply.
Do you plan to perform any evaluation activities around Hip Hop Public Health's materials?
*
For instance, do you plan to pre/post test your audience on their knowledge around a particular health topic?
Please provide information here with more details on how you intend to use our materials, if applicable.
What are your thoughts on hip hop music as a tool to excite children in your community around health education?
*
Please record your thoughts below.
How did you find out about Hip Hop Public Health?
Ways
*
Please select all that apply.
Website
Facebook
Twitter
YouTube
The Partnership for a Healthier America
Professional Organization
Media
Web search
Friend/Colleague
Other
Other way
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