Attachment_1b

Attachment 1b

Registration Form for EPA’s SunWise Program

Your Name: _____________________________________________________________________

How did you learn about SunWise? ___________________________________________________

________________________________________________________________________________

About Your Organization

My organization is a: Childcare Center / Pre-K Museum Civic Group

Science or Health Ed. Center Not-for-profit Health Org. University

Government Other:_________________________________________

Org. Name: _____________________________________________________________________

Org. Address: ___________________________________________________________________

City: ___________________________________ State:__________ Zip Code: ________________

Phone: (_______)__________________________ County: ________________________________

Your E-mail : ____________________________________________________________________

Org. Web site: ___________________________________________________________________

Mailing Address: Please send materials to: My Organization (listed above)

Another Address (enter below)

Alternate Address: ________________________________________________________________

City: ___________________________________ State:__________ Zip Code: ________________

Phone: (_______)_________________________________________________________________

Number of students you plan to teach SunWise in a year: _________________________________

How do you plan to use the kit (i.e., on testing days as a fun break for students, during our solar unit, or at the beginning of outdoor activities, during rainy day P.E. activities, etc.)? _________________

________________________________________________________________________________

________________________________________________________________________________

Language: English Materials OR Spanish Materials?

In keeping with the EPA's commitment to program evaluation, are you willing to be contacted periodically regarding SunWise? Yes No

Incomplete Forms May Not Be Processed

Information collection via this form is authorized by OMB Control No. 2060-0439