Advanced Master Gardener Outreach Form

Name:  __________________________________________  Phone:  __________________________

Address:  ________________________________________  County:  __________________________

Year Certified:  __________________

Total Outreach Hours:   ___________

Outreach Service:  Please describe project name, educational objective, audience, location and contact person.  Programs must be open to the public without regard to race, religion, national origin, sex, age or disability.  Programs must be free or nominal cost for materials only.

                                            Project Name:   _____________________________________________

                                            Location:   _________________________________________________

Contact Person:                Name:           _______________________________________________

                                           Address:   ______________________________________________________

                                            Town:  _______________________________ Zip _________________

                                            Phone:  ______________________________

Project Description (must have an educational focus) - attach paper as needed.

Do not begin outreach activity without prior approval!

Signature of Approval:  ________________________________________   Date:  _________________

                                         Master Gardener Program Coordinator

The University of Connecticut Cooperative Extension System has developed this publication.  Any reprint or direct use of any part of this document may not occur without prior written approval of the author.