Hip Hop Public Health – Ambassador Submission

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.

SUBMIT

Hip Hop Public Health – Ambassador Submission

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Please complete all required fields (*)

Address

Have you ever been arrested for any crime?

Have you ever been convicted of a misdemeanor?

Have you ever been convicted of a felony?

Which Hip Hop Public Health educational topics are you interested in?

Which multimedia materials do you plan to use?

How many times or at how many sessions do you plan show the materials to children?

How many children do you plan to deliver the materials to at each session?

Over what period of time do you plan to use our materials?

What is the age range of the children you plan to deliver the HHPH materials to?

What is the prominent race/ethnicity of the children you plan to reach with the HHPH materials?

In what type of community do you plan to deliver the materials?

Where do you plan to reach children with the HHPH materials?

How did you find out about Hip Hop Public Health?