Attachment 1a

Attachment 1a

Registration Form for EPA’s SunWise Program

Your Name: _____________________________________________________________________

How did you learn about SunWise? ___________________________________________________

________________________________________________________________________________

About Your School

Please select your position at school: Teacher Nurse Counselor

PTA member Principal/Administrator School District Employee

Student Teacher Substitute Teacher Other:_______________________

School Name: ___________________________________________________________________

School Address: __________________________________________________________________

City: ___________________________________ State:__________ Zip Code: ________________

Phone: (_______)__________________________ County: ________________________________

Your E-mail : ____________________________________________________________________

School Web site: __________________________________________________________________

Is your school: Public Non-charter Private Charter

Grade(s) you teach: Pre-K K 1 2 3 4 5 6 7 8 9-12

Subjects you teach: Science Social Studies Math English ESL Health

School Nurse Physical Education Env. Studies Other:_____________________

Estimated number of total students in your school: ______________________________________

Number of students you plan to teach SunWise in a year: _________________________________

How do you plan to use the kit (i.e., on testing days as a fun break for students, during our solar unit, or at the beginning of outdoor activities, during rainy day P.E. activities, etc.)? _________________

________________________________________________________________________________

Language: English Materials OR Spanish Materials?

In keeping with the EPA's commitment to program evaluation, are you willing to be contacted periodically regarding SunWise? Yes No

Incomplete Forms May Not Be Processed

Information collection via this form is authorized by OMB Control No. 2060-0439