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   *Required Information      

* YES, I want to be a part of "Chill Smart"

 
*Date: / /
*First Name:
*Last Name:
*Age:
*Address:
*City:
*State:
*Zip Code:
*Telephone: ( ) -
*Email:

*Name of Emergency Contact:
*Emergency Phone number: ( ) -

Name of School:
       
   

Would you like to: ....

  1. Help plan fun youth activities?
  2. Be informed about upcoming events?
  3. Like to help out only for special events?
  4. Recieve emails about Chill Smart?
  5. Help get more youth signed up?
  6. Learn more about the dangers of alcohol?
 
         
 
         
   
             
 
* All information submitted WILL be kept confidential
  
             

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