mindout - local activity form

We would be very grateful if you could complete this form in advance of any activity, or series of activities that you are planning as part of your participation in the campaign.

The information you provide will help us to keep abreast of local activity, so that we can inform partner organisations and other local groups about events in specific areas, and identify stories that can help build momentum, or inspire media activity, at the national level.

There are two ways to complete this form:

Fill in the fields on this page and press the 'Submit' button.
Print out a version of this form to fill in and send by post.

Please complete the fields and checkboxes below:

Date(s) of planned activity(ies):

Main target audience(s):
Please tick relevant boxes and give further details below.

	General Public
	Media
	Youth
	Employers
	Other

More details about your intended target audience:

Description of your planned activity / activities:

Other groups or organisations involved:

Local media you are contacting:
Please tick relevant boxes and give further details below.

	Local papers
	Free press
	Local TV
	Local radio
	Other

More details about media you are contacting:

Full name

Group Name

Mailing Address Line 1

Mailing Address Line 2
(optional)

Town / city

County
(optional)

Postcode

E-mail address

Phone

Fax

We may wish to publish some of your comments or refer to your activities.

Please check this box: if you do NOT wish this to happen.

Thank you for keeping us informed about your plans.