Limit one copy per order.
All orders must list the name of the organization, and the purpose and audience for which the film will be used. Because dissemination funds are limited, we are unable to provide more than one copy of the film per individual or organization. If you or your organization have a unique need that requires additional copies, they can be purchased at a cost of $10.00 each by sending an e-mail request directly to HIVPositiveVoices@jhsph.edu. Payment instructions will follow.
Name of Organization:
Name:*
Title:
Address Line 1:*
Address Line 2:
City:*
State:*
Zipcode:*
Country:*
Phone:*
Fax:
E-mail:
If this is an Urgent request, please enter the date the film is needed:
Would you like to have a copy of the film for your permanent use? *
Yes No
If so, what format? *
VHS DVD PAL
How would you plan to use a permanent copy? *
Are you having an event for which you would like to show the film?
Name of Event:
Date / Time:
Brief Description:
Location:
Sponsor(s):
Target Audience(s):
Event Contact / Phone Number:
Would you like us to post this event on this wesbite?
An auxiliary organization called "Positive Choices, Positive Voices" can sometimes offer speakers who are HIV Positive. Their appearances are compensated by the host organization with an honorarium of $100. Speaker Requests are for Baltimore only unless you are willing to accommodate travel expenses.
Would you like to have a speaker talk to your group?
If so, which mode of transmission is most relevant to your program?
Perinatal Transmission Heterosexual Transmission Injection Drug Use Men Having Sex With Men All of the above Other: (explain below)
Do you have the resources to compensate a speaker up to $100?
How did you hear about this video?
Friend Colleague Church School Community Org. Television Radio Internet Other
If Other, please explain here:
Please use this space for any other comments or questions:
* = required field
