Project Prevent Chapter Registration 2023-24

Question Title

1. School or Organization Name

Question Title

2. Chapter Name

Question Title

3. Advisor's Name

First

Last

Question Title

4. Phone Number

Question Title

5. Email Address

Question Title

6. Shipping Address (No PO Boxes)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Question Title

7. County

Question Title

8. Total Number of Chapter Members

Question Title

9. Number of African American Chapter Members

Question Title

10. Number of Caucasian Chapter Members

Question Title

11. Number of Chapter Members of Other Races/Ethnicities

Question Title

12. Total Number of Males

Question Title

13. Total Number of Females

Question Title

14. Grade Level of Chapter Members

7th - 12th

4th - 6th

Other (please specify)