Registration Form for EPA’s SunWise Program

Your Name:
_____________________________________________________________________

How did you learn about SunWise?
___________________________________________________

________________________________________________________________________
________

About Your School

Please select your position at school:   	  FORMCHECKBOX   Teacher	 
FORMCHECKBOX   Nurse	  FORMCHECKBOX   Counselor	

  FORMCHECKBOX   PTA member 	  FORMCHECKBOX   Principal/Administrator		 
FORMCHECKBOX   School District Employee	

  FORMCHECKBOX   Student Teacher	  FORMCHECKBOX   Substitute Teacher			 
FORMCHECKBOX   Other:_______________________

School Name:
___________________________________________________________________

School Address:
__________________________________________________________________

City: ___________________________________ State:__________ Zip Code:
________________

Phone: (_______)__________________________ County:
________________________________

Your E-mail :
____________________________________________________________________

School Web site:
__________________________________________________________________

Is your school:      FORMCHECKBOX   Public Non-charter	  FORMCHECKBOX  
Private	  FORMCHECKBOX   Charter 

Grade(s) you teach:    FORMCHECKBOX  Pre-K      FORMCHECKBOX  K	    
FORMCHECKBOX  1      FORMCHECKBOX  2      FORMCHECKBOX  3     
FORMCHECKBOX  4      FORMCHECKBOX  5      FORMCHECKBOX  6     
FORMCHECKBOX  7      FORMCHECKBOX  8      FORMCHECKBOX  9-12

Subjects you teach:    FORMCHECKBOX   Science     FORMCHECKBOX   Social
Studies     FORMCHECKBOX   Math      FORMCHECKBOX   English     
FORMCHECKBOX   ESL      FORMCHECKBOX   Health

  FORMCHECKBOX   School Nurse      FORMCHECKBOX   Physical Education    
 FORMCHECKBOX   Env. Studies      FORMCHECKBOX  
Other:_____________________

Estimated number of total students in your school:
______________________________________

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:   FORMCHECKBOX   English Materials 	OR 	  FORMCHECKBOX  
Spanish Materials?

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

Attachment 1a

Incomplete Forms May Not Be Processed

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

