Project Prevent Chapter Registration 2022-23

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1. School or Organization Name

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2. Chapter Name

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3. Advisor's Name

First

Last

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4. Phone Number

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5. Email Address

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6. Shipping Address (No PO Boxes)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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7. County

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8. Total Number of Chapter Members

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9. Number of African American Chapter Members

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10. Number of Caucasian Chapter Members

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11. Number of Chapter Members of Other Races/Ethnicities

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12. Total Number of Males

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13. Total Number of Females

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14. Grade Level of Chapter Members

7th - 12th

4th - 6th

Other (please specify)