2017 NIAW Event Survey

Thank you for planning an event during National Infertility Awareness Week® (NIAW) Please remember to submit information for each event separately. All events will be posted within 3 business days. Postings received without sufficient information or that are not related to NIAW will be returned to the individual submitting the event.
*1.



Question – Required –

Date event takes place

Month
Month

Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec

Day
Day

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Year
Year
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917

 

*2.
Question – Required –


Time event takes place, including US Time Zone (example: 9:00PM – 10:00PM)

 

*3.
Question – Required –


Location of the event:

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

*4.
Question – Required –


Title of Event (40 character limit)

 

*5.
Question – Required –


50 word description of event, including the name of the business hosting the event, the cost to attend and a contact name, phone number and URL link for consumers to register for the event or ask questions.

 

6. Please fill out the following information:

* Name:

First Required

Last Required

* Email: Required
  Street 1:
  Street 2:
  City/State/ZIP:

City

State

ZIP

AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AS
FM
GU
MH
MP
PR
PW
VI
AA
AE
AP
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
None

Required

  Phone Number:
  Yes, I would like to receive e-mail from RESOLVE: The National Infertility Association
  Yes, I would like to receive postal mail from RESOLVE: The National Infertility Association

 

*7.
Question – Required –


Event Contact First Name:

 

*8.
Question – Required –


Event Contact Last Name:

 

*9.
Question – Required –


Event Contact Email:

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

*10.
Question – Required –


Company/Organization Name (hosting the event):

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

*11.
Question – Required –


Company/Organization Address:

 

*12.
Question – Required –


Contact Phone Number:

 

*13.
Question – Required –


Specialty:

 

Please select response
Adoption Agencies
Attorneys
Coaching & Consultants
Complementary Treatment
Mental Health
Pharmacies
Physicians/Fertility Clinics
Third Party Reproduction
Other

 

14.
Question – Not Required –


Company Street Address (if different than the location address):

 

15.
Question – Not Required –


Company Street Address 2: (if different than the location address):

 

16.
Question – Not Required –


Company City (if different than the location address):

 

17.
Question – Not Required –


Company State (if different than the location address):

 

18.
Question – Not Required –


Company zip code (if different than the location address):

 

Spam Control Text:
Please leave this field empty