Media Report

Please print out this page or download a copy (right click the link and save), and complete.

Contact Name: ______________________________________________________________________

Facility Name: _______________________________________________________________________

Facility Address: _____________________________________________________________________

City, State, ZIP: _____________________________________________________________________

Phone Number: ______________________________________________________________________

Date of Report: ______________________________________________________________________

Please list the results of your local publicity effort. Whenever possible, please attach a copy of the story which ran in the newspaper.

Media Name/Location

Date of Coverage

Type of Coverage

Newspapers:

1. _________________________________________________________________________________

2. _________________________________________________________________________________

3. _________________________________________________________________________________

4. _________________________________________________________________________________

Radio

1. _________________________________________________________________________________

2. _________________________________________________________________________________

3. _________________________________________________________________________________

Television

1. _________________________________________________________________________________

2. _________________________________________________________________________________

Please attach clips, audio or video copies if available.

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