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* 1. Please complete the following and list the address where you would like your students' McDonald's Fruit Smoothie Coupons mailed:

Please provide the following information for each class participating in the iCivics Arizona Program.  If you have multiple classes participating, please track the information under the same class number each time you return to this form.  This will ensure that the totals are tracked correctly for each class participating in this program and iCivics Arizona Competition.
CLASSROOM #1

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* 2. Grade Level

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* 3. Total number of McDonald's Smoothie Coupons requested:

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* 4. Total number of participating students for which you are requesting a McDonald's Smoothie Coupon (200 or more minutes required per student):

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* 5. Total number of MINUTES played by all participating students listed above that earned a McDonald's Smoothie Coupon (at a minimum, the totals should include 200 minutes x number of students = total minutes played):

CLASSROOM #2

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* 6. Grade Level

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* 7. Total number of McDonald's Smoothie Coupons requested:

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* 8. Total number of participating students for which you are requesting a McDonald's Smoothie Coupon (200 or more minutes required per student):

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* 9. Total number of MINUTES played by all participating students listed above that earned a McDonald's Smoothie Coupon (at a minimum, the totals should include 200 minutes x number of students = total minutes played):

CLASSROOM #3

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* 10. Grade Level

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* 11. Total number of McDonald's Smoothie Coupons requested:

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* 12. Total number of participating students for which you are requesting a McDonald's Smoothie Coupon (200 or more minutes required per student):

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* 13. Total number of MINUTES played by all participating students listed above that earned a McDonald's Smoothie Coupon (at a minimum, the totals should include 200 minutes x number of students = total minutes played):

CLASSROOM #4

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* 14. Grade Level

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* 15. Total number of McDonald's Smoothie Coupons requested:

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* 16. Total number of participating students for which you are requesting a McDonald's Smoothie Coupon (200 or more minutes required per student):

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* 17. Total number of MINUTES played by all participating students listed above that earned a McDonald's Smoothie Coupon (at a minimum, the totals should include 200 minutes x number of students = total minutes played):

CLASSROOM #5

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* 18. Grade Level

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* 19. Total number of McDonald's Smoothie Coupons requested:

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* 20. Total number of participating students for which you are requesting a McDonald's Smoothie Coupon (200 or more minutes required per student):

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* 21. Total number of MINUTES played by all participating students listed above that earned a McDonald's Smoothie Coupon (at a minimum, the totals should include 200 minutes x number of students = total minutes played):

To complete this submission or to enter totals and request smoothies for additional classrooms, please advance to the next page by clicking "Submit".

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