Salutation:

The HonorableMr.Ms.Mrs.MissDr.Rev.Sister First: M.I.:

Last:

Suffix: Sr.Jr.IIIIV

Organization*:

Title:
*-Individuals may opt to enter "NONE" in this required field.

Is this organization an afterschool program? Yes No

Address 1:

Address 2:

City:

State: AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Zip:

Email:

W. Phone:

Ph. Extension: Fax:

How would you describe yourself?

Afterschool Program Staff Afterschool program volunteer Business professional Civil servant Concerned citizen Educator Elected Official Media Parent/guardian Public interest professional Youth (under 18)

Do you have children who participate in afterschool programs?

Yes No

Where did you hear about the Afterschool Alliance?

Afterschool Alliance mailing Search engine TV or Radio ad Colleague Website Afterschool program Afterschool conference News story JCPenney

If you would like to take advantage of the premium features the Afterschool Alliance websites offer, please enter a password:

Confirm Password:

Forgotten password trigger: In what city were you born?

The Afterschool Alliance periodically sends newsletters, afterschool alerts, and updates via email, If do not want to receive emails from the Afterschool Alliance check "No" here:

Yes, email me.
No, do not email.

From time to time, the Afterschool Alliance may share contact information with organizations of similar mission on a one-time basis if the material is deemed by the Alliance to be appropriate and of interest to those concerned with afterschool issues. If you do not want your contact information to be shared, please check "No" here:

Yes, share my information with appropriate organizations.
No, do not share my information.