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Project Prevent Chapter Registration 2023-24
1.
School or Organization Name
(Required.)
2.
Chapter Name
(Required.)
3.
Advisor's Name
(Required.)
First
Last
4.
Phone Number
5.
Email Address
(Required.)
6.
Shipping Address (No PO Boxes)
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
7.
County
(Required.)
8.
Total Number of Chapter Members
(Required.)
9.
Number of African American Chapter Members
(Required.)
10.
Number of Caucasian Chapter Members
(Required.)
11.
Number of Chapter Members of Other Races/Ethnicities
(Required.)
12.
Total Number of Males
(Required.)
13.
Total Number of Females
(Required.)
14.
Grade Level of Chapter Members
7th - 12th
4th - 6th
Other (please specify)