Wichita Mountains Prevention Network

Date

Your Name

Contact Email

Phone

Agency/Organization

County

Primary Target Population

Male    Number of Males in Primary Target Population who will be using materials.

Female Number of Females in Primary Target Population who will be using materials

0-5   Number of individuals ages 0-5 in Primary Target Population who will be using materials

6-11 Number of individuals ages 6-11 in Primary Target Population who will be using materials

12-14 Number of individuals ages 12-14 in Primary Target Population who will be using materials

15-17 Number of individuals ages 15-17 in Primary Target Population who will be using materials

18-20 Number of individuals ages 18-20 in Primary Target Population who will be using materials

21-24 Number of individuals ages 21-24 in Primary Target Population who will be using materials

25-64 Number of individuals ages 25-64 in Primary Target Population who will be using materials

65+ Number of individuals ages 65+ in Primary Target Population who will be using materials

White Number of individuals by Ethnic Origin (White) who will be using materials

African American Number of individuals by Ethnic Origin (African American) who will be using materials

Asian Number of individuals by Ethnic Origin (Asian) who will be using materials

Hispanic/Latino Number of individuals by Ethnic Origin (Hispanic/Latino) who will be using materials

American Indian Number of individuals by Ethnic Origin (American Indian) who will be using materials

Other Number of individuals by Ethnic Origin (Other) who will be using materials

Clearinghouse Request Please list by inventory number from the online catalog the items you need and quantity you wish for each item.