Chair Name *

First Name

Last Name

Phone *

(###)

###

####

Status *

For this month...

Active

Inactive

Status of Achieving Goals *

Green (on target to achieve on time)

Yellow (some unforeseen obstacles; may need to change deadline)

Red (goals may not be achieved)

N/A (not currently active/no current goals)

Would you like to make an announcement/have an announcement made on your behalf at the upcoming board meeting?

Yes

No, everything is covered in my report