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#3 2006 Back Up your
Birth Control Planning Form
Name ________________________________________________________________
Address_______________________________________________________________
Organization____________________________________________________________
Phone_____________________________Email_______________________________
Date(s) of you Back Up your Birth Control Activities _____________________________
How will the Back Up Your Birth Control Campaign fit into
your organizational goals for 2006?
What type of Back Up Your Birth Control
education or outreach activities are you planning?
Who is your target audience? How will you reach
them?
What type of sample documents or materials will
you use to prepare for your activity?
What type of other materials, not already provided
by the Back Up Your Birth Control Campaign, would be useful
to your efforts?
| Back Up Your Birth Control Activity |
Type of Materials |
Goals |
| Local Media Activities: |
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# of Local Media Contacted |
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| Public Awareness Activities: |
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# People Attending Event or Receiving Materials |
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| Campus Activities: |
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# People Attending Event or Receiving Materials |
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| Legislative Activities: |
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# of Legislators Contacted |
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| Engaging the Medical Community: |
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# People Contacted |
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Use additional sheets if necessary.
Please return to the Back Up your Birth Control Campaign
by March 21st, 2006
427 Broadway, 3rd Floor, NY, NY 10013,
(P) 212-343-0114 x25, (F) 212-343-0119, info@buybc.org
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