My Brother's Keeper Community Information Form

My Brother's Keeper Community Information Form

Dear MBK Community Leader:

Thank you for taking the time to complete the following form. We want to make sure we have your most up-to-date contact information as well as the status of your progress and plans towards completing the MBK Community Challenge. If you have any questions, please e-mail LocalGovernment@who.eop.gov.

Thank You

For your submission

Primary Point of Contact:

First name

Last name

Title

Email address

Phone number

Mailing Address

City

State

Zip

Alternate Point of Contact:

First name

Last name

Title

Email address

Phone number

Email that can be shared publicly (i.e., MBK@SpringfieldCity.gov)

URL where the public can find information about your MBK program, if applicable

Name of your MBK program, if applicable (i.e., My Brother's Keeper Gary)

Your MBK hashtag, if applicable (i.e., #MBKBoston)

Date of local action summit (or planned date)

Date policy scan was completed (or planned date)

Date of Local Action Plan release (or expected date)

Please give us an update on your progress. Tell us about recent or upcoming events or rollouts and how you’re making progress against your goals.

If you have not yet released your Local Action Plan, please provide a brief description of your progress to date and your process to complete. Be sure to let us know any early thinking on goals, activities, planned convening, etc., and any unexpected challenges or opportunities you've encountered.

*Required Field