School or Organization Name

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* 1. School or Organization Name

Chapter Name

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* 2. Chapter Name

Sponsor's Name

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* 3. Sponsor's Name

Phone Number

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* 4. Phone Number

Email Address

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* 5. Email Address

Shipping Address (No PO Boxes)

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* 6. Shipping Address (No PO Boxes)

Date of Activity

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* 7. Date of Activity

Date / Time
Title of Activity

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* 8. Title of Activity

Activity Topic

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* 9. Activity Topic

Activity Description

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* 10. Activity Description

Did media cover the event?

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* 11. Did media cover the event?

# of Project Prevent Chapter Members who participated in the activity

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* 12. # of Project Prevent Chapter Members who participated in the activity

T