Survey - Start a Dance Marathon - Boston Children's Hospital

Start a Dance Marathon

Ready to join the national movement and bring Dance Marathon to your school? Tell us a bit about yourself and fill out the form below! Have some questions first? Contact Nikki Benoit at nicole.benoit@chtrust.org or (857) 218-3144.

1.

Contact informaiton:

*

Name:

First Required	Last Required

*

Email: Required

*

Primary Phone Number: Required

Yes, I would like to receive e-mail from Boston Children's Hospital

*2.

Question - Required - When do you plan to host your Dance Marathon?

*3.

Question - Required - Dance Marathon type: Middle School
High School
College/University

*4.

Question - Required - School name:

*5.

Question - Required - School location (city, state):

*6.

Question - Required - How are you affiliated with this school (i.e. student, faculty, staff, administration)?

*7.

Question - Required - What grade are you currently in or what is your job title?

*8.

Question - Required - Will your Dance Marathon be affiliated with a student organization (i.e. Sorority, National Honor Society)? Yes
No

9.

Question - Not Required - If yes, what is the name of the student organization?

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

*10.

Question - Required - How did you hear about Dance Marathon?

Start a Dance Marathon

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