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Middle School and Youth Group Registration Form
Registration deadline is August 26 at 5:00pm.
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* Indicates required question
Name of Your Middle School or Youth Group:
*
Your answer
Please select how your school or youth group will be participating:
*
Our school or youth group will compete for prizes.
Our school or youth group will not be competing.
Address:
*
Your answer
Telephone Number:
*
Your answer
Number of Students in your Club or Youth Group:
*
Your answer
Number of Male Students:
*
Your answer
Number of Female Students:
*
Your answer
Adult Contact
*
Please list the first and last name of the adult assisting students with the campaign.
Your answer
Telephone Number:
*
Your answer
E-Mail:
*
Your answer
If a school, what is the current student enrollment?
*
Your answer
How many 'Buckle Up Reminder' Cards would you like to order?
*
0
50
100
200
300
How many 'Buckle Up and Be a Safe Passenger' Posters would you like to order?
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0
10
15
25
How many 'Drive for Change: Buckle Up and Be a Safe Passenger' Banners would you like to order?
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0
1
How many Mandala Art Activity Sheets would you like to order?
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There are two activity sheet designs so we will split your order between the two.
0
50
100
150
200
How many 'The World Needs You: Buckle Up' Stickers would you like to order?
*
There are two activity sheet designs so we will split your order between the two.
0
25
50
100
How many 'Drive for Change' Flashing Car Keychains would you like to order?
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0
50
100
How many 'Make Good Choices' Halloween Posters would you like to order?
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0
10
15
25
How many Glow in the Dark Wristbands would you like to order?
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0
50
100
How many Halloween Treat Bags for Elementary Programs would you like to order?
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0
50
100
How many Halloween Activity Books for Elementary Programs would you like to order?
*
0
25
50
100
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