Planned Parenthood : Survey - Academic Projects- Information Request Form

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Question - Required - *Name:

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Question - Required - *Phone Number:

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Question - Required - *E-mail Address:

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Question - Required - *Name of the academic institution:

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Question - Required - *Name of the class:

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Question - Required - *Name of your professor:

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Question - Required - *Professor's E-mail Address:

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Question - Required - *Have you already contacted a staff member?

Question - Not Required - If YES, please type the name of the PPGC employee:

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Question - Required - *What is your project about?

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - *What is your deadline?

Month

Day

Year

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Question - Required - *Do you need quotes from someone at PPGC?

Question - Not Required - If YES, please type the specific questions you need answered with quotes (Max. 3):

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - *Please type the unanswered questions for your project (Make sure you have already reviewed the website. Most of our information is there, including our mission and vision):

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Question - Required - *Do you need printed materials? (Brochures, our history information, etc.) If you mark YES, there will be an information package ready for you to pick up at the Planned Parenthood Gulf Coast- Prevention Park location: 4600 Gulf Freeway Houston, TX 77023

Question - Not Required - Comments or questions:

(Maximum response 255 chars, approx. 5 rows of text)