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KU Medical Center Community Partnership Award in Community Engagement

Project or Event Title:

Project or Event Location (city, state):

Brief explanation of the project (500 character max):


Please attach a narrative of the project or event: (10MB max)

Primary Organization Name:

Address:

City: State: Zip:

Phone number:

Email:

Name of contact person

Other Organization Name:

Address:

City: State: Zip:

Phone number:

Email:

Name of contact person

KU Medical Center Faculty Member:

Address:

City: State: Zip:

Phone number:

Email:

Other KU Medical Center Faculty Member:

Address:

City: State: Zip:

Phone number:

Email:

Were KU Medical Center students involved? Yes       No 
If yes, please list names of the Medical Students involved:


Were KU Medical Center staff involved? Yes       No 
If yes, please list names of the staff memebers involved:


Nominator Information:
Name:

Address:

City: State: Zip:

Phone number:

Email:

Last modified: Apr 04, 2013