AIDS Memorial Quilt Display Application

. • Required Fields

Applicant Info
• Organization hosting display
• Address of display
• City
• State
• Zip
• Name of Event
 

Display Dates
• Start Date of Display
 Time
• End Date of Display
 Time

 

Organization Contact
• Name
Title
• Phone
Extension
Fax
• Email
Display Information
• Number of 12X12 panels of the Quilt you would like to display


(Specific panel numbers should be requested as far in advance as possible. The NAMES Project Chapter determines the number of Quilt panels available.)
List any specific Quilt Panels you are requesting:
#

#

#
• Date you would like to pick up the Quilt panels
• Our organization will donate an honorarium to the NAMES Project, NY Capital Region Chapter for the display in this amount:
$
Is this display wheelchair accessible?
Will you need any printed materials from the NAMES Project?


If so, which one(s)?

• We have volunteers to help staff this event.


We need additional staffing from the NAMES Project Chapter.
Additional Information
Briefly describe any additional requests you may have of the NAMES Project
• Briefly describe the goals of your display
List any HIV/AIDS related education/prevention activities occurring concurrently with the display and any other AIDS Service Organizations that will be present
• Describe the exhibit area and plans for displaying the Quilt, including how the Quilt panels will be displayed
• Describe on-site security measures that will be taken to protect the Quilt panels while displayed and stored
• Name of Event Planner
• Date of Request