REQUEST MUST BE RECEIVED 3 WEEKS PRIOR TO EVENT

School/Business Name __________________________________________________________

Address _________________________________City________________ Zip______________

Contact Name ___________________________ Email ________________________________

Phone____________________________ Fax ________________________________________

Date of Event___________________________ Time _______AM/PM to ________ AM/PM

Location of Event______________________________________________________________
(if location is different from address above)

Audience ___________________________________(number of attendees and age range)

Specify Type of Speaker you would like for your event:

_____ Drunk Driving Crash Victim
_____ General MADD Information
_____ MADD Victim Service
_____ Youth Prevention Speaker
_____ Other

Comments: ______________________________________________________________

________________________________________________________________________

MADD is dedicated to raising public awareness regarding drunk driving, victim services and underage drinking.
The following fees have been developed to defer speaker and travel expenses.
Please note: If you are a school you are eligible for one scholarship per school calendar year.

_____ $100 Individual Class
_____ $100 Civic Groups
_____ $100 Parent Forum
_____ $100 Department of Corrections
_____ $250 School Assembly

This document serves as an agreement of your partnership with our organization. An invoice will be sent after the event.

Upon receipt, a MADD representative will contact you.
Email: Terri.johnson@madd.org
Fax: 651-523-0817 (attn: Terri Johnson)
Mail to: Terri Johnson
MADD Minnesota
155 South Wabasha Street, Suite 104
St. Paul, MN 55107