Site Information Form


This form is to be used by locations outside the Florida Department of Health's Distance Learning Satellite Network (DLSN) wishing to participate in a satellite broadcast listed on the schedule. If you have any questions about this form, please contact the DLSN staff at 850-245-4008.


Broadcast Title

Broadcast Participation


Audience
Estimated Live Audience (1 - 150)
Estimated Videotape Audience (1 - 150)

How did you hear about this program?


Site Information
Site Name
Street Address
City
State
Zip

Agency




















Site Coordinator (Please note that an email is needed to obtain broadcast materials and viewing information.)
Name
Phone (include extension)
Email
Would you like to be added to our distribution list for future satellite broadcast announcement emails?
Yes   No  
Would you like to become a partner in the Florida Department of Health’s Distance Learning Satellite Network?
Yes   No  

Back-up Coordinator or Technician (optional)
Name
Phone (include extension)
Email
Would you like to be added to our distribution list for future satellite broadcast announcement emails?
Yes   No  
Would you like to become a partner in the Florida Department of Health’s Distance Learning Satellite Network?
Yes   No  

The following questions are for those locations participating by satellite system. If you are participating by webcast, please skip room information questions.

Room Information: Which of the following do you use to view broadcasts?








Satellite Receiver Information
Dish size (please specify meters or feet in your response)
Ground Pole Mount Dish
Yes   No  
Receiver Model





Surge Protection


Brand of Surge Protection
Satellite Receiver Type (Check all that apply)






Additional Questions or Comments: