Registration Form for EPA’s SunWise Program

Your Name:
_____________________________________________________________________

How did you learn about SunWise?
___________________________________________________

________________________________________________________________________
________

About Your Organization

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

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

  FORMCHECKBOX   Government			  FORMCHECKBOX  
Other:_________________________________________

Org. Name:
_____________________________________________________________________

Org. Address:
___________________________________________________________________

City: ___________________________________ State:__________ Zip Code:
________________

Phone: (_______)__________________________ County:
________________________________

Your E-mail :
____________________________________________________________________

Org. Web site:
___________________________________________________________________

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

						  FORMCHECKBOX   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: 	  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 1b

Incomplete Forms May Not Be Processed

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

