General Community Site Activity Form

To join We Can!, please fill out all necessary information, and click the "submit" button at the bottom of this page. If you prefer to fax your information, please download and print a PDF Version of this form and fax a completed form to the NHLBI Health Information Center at (240) 629-3246.

Completing this form indicates your willingness to post your activities for public use. Before we can post your activities, you must identify yourself so that we can verify or clarify any information if necessary. The NHLBI will use your personal information only in the ways indicated in our Privacy Statement at http://www.nhlbi.nih.gov/about/privacy.htm. Submissions that promote businesses or commercial activities or products will not be accepted.

Intended Level of Commitment

I have read and agree to the We Can!™ Brand and Logo Guidelines

Please specify your intended level of effort:

General Community Site	Intensive Community Site	We Can! City

I'd like information about becoming a We Can! Partner. View the We Can! Partner Commitment Form

Contact Information

Please provide contact information.

Completing this form to list your information on the We Can! Web site is voluntary. However, before we can post your information, you must identify yourself so that we can easily verify or clarify any information if necessary. The NHLBI will use your personal information only in the ways stated in our privacy statement. View our privacy statement at http://www.nhlbi.nih.gov/about/privacy.htm

* Denotes a required field
Primary Point of Contact
* First Name:
MI:
* Last Name:
Title:
* Name of Organization/Coalition:
Mailing Address 1: (Please No P.O Boxes)
Mailing Address 2:
City:
State:
Zip:
* Phone:
Fax:
* E-mail:

We Can! Community Sites Resources

To assist your planning, implementation, and overall We Can! experience, please review and SELECT the communication formats you would like to receive.

Permission to post your activities on the We Can! Web site-We Can! Let us know if we can share your experiences, and post your organization's name, city and state as a new We Can! Community Site.

Permission to communicate with We Can! national organizers-Let us know if we can give We Can! national organizers the authority to contact you via e-mail, mail, or phone to ensure your success. Your contact information will not be used in any activities other than We Can! support and will not be shared with any outside parties. Privacy Statement

We Can! Community Site Listserv-Let us know if you would like to join a listserv that connects community sites across the country and provides announcements of NIH resources and research, the opportunity to request NIH print resources to enhance programming, and the ability to discuss your programming with other sites.

We Can! in Action e-Newsletter-Let us know if you would like to receive the program's e-newsletter. For a preview, follow this link.

We Can! Community Site Starter Kit
Once you are registered as a We Can! Community Site, we will send you a free We Can! Community Site Starter Kit that includes one of each of the following materials:

We Can! Community Toolkit: Energize Our Community: Toolkit for Action (this toolkit contains the We Can! Parent Curriculum)
We Can! Program Poster: Who can make it happen? We Can!
We Can! Brochure
We Can! Parent Handbook: Families Finding the Balance: A Parent Handbook (in English and Spanish).
We Can! wristbands (one adult-size and one child-size bracelet)
We Can! Products & Order Information Form

You have now completed the We Can! Sign-Up Form! Please click the "Submit" button below and your form will be sent to We Can! national organizers.

If you have any questions regarding this process, please contact the NHLBI Health Information Center by e-mail at nhlbiinfo@nhlbi.nih.gov or by phone at 301-592-8573; TTY: 240-629-3255; or toll-free at 1-866-35-WECAN.