The Dibble Institute

Especially for Smart Marriage Conference Attendees

Name of Individual/Position:
School Organization:
Day Phone:
Evening Phone:
Cell Phone:
Fax:
Address:
City:
State:
Zip:
Email Address:
Brief Description of School/Organization:
Current Activities/Classes YOU LEAD with opportunity to provide relationship education:
Proposed activity/class YOU WILL LEAD to provide relationship education. Number of sessions and amount of time per session:
Age range of students:
Number of students you can commit to teaching relationship skills education by May 30, 2010:
What curriculum are you planning to utilize?:	Connections: Dating and Emotion Connections: Relationships and Marriage Connections: Relationships and Marriage (Spanish) Love U2: Relationships Smarts PLUS Love U2: Baby Smarts
Describe how you will complete the required number of curriculum hours. Please indicate the support of your organization/school to participate in this project.
If number of teens recruited is below your estimate, what additional opportunities can be implemented to reach your goal?
Nominated by:
Nomination Approved: (Nomination may be submitted by the individual nominee or their organization.)

Funding for this project was provided by the United States Department of Health and Human Services, Administration for Children and Families, Grant Number: 90-FE-0024.Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the United States Department of Health and Human Services, Administration for Children and Families.