Please use this form if you are registering more than one Lights On Afterschool! event. The contact information that you provide on this first screen will be used as your primary contact information; therefore, please use this screen to enter the event with which you are most directly associated.

Your program and contact information will be listed on this site's "Find an Event" page. (*--indicates required fields. Please leave blank any non-required fileds for which you do not have and/or wish to provide an answer.)

Register Here

Enter your contact information below. Once you submit it, a new screen will appear to enter contact information for the other sites.

PLEASE NOTE: If you do not provide contact information for each site, we cannot send them Planning Emails or Posters. Please email or call us if you have concerns about this form or getting materials to these sites.
Total Number of Events:

Name:
Prefix: Dr. Ms. Mr. Mrs. Rev. Sister First*: M.I.: Last*:
Suffix: II III Jr. Sr.
Title:
E-mail*:
Phone*: use form xxx-xxx-xxxx
Ext.:
Fax: use form xxx-xxx-xxxx

Program/Organization*:

Program Address (line 1)*:

Address (line 2):

City*: State*: AK AL AP 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*:
Website: (please use the form " http://www.yoursite.org ")

At our event on October 16, we plan to:


Check boxes below if you plan to invite:

Mayor	Governor
Superintendent	Member of U.S. Congress
State Legislator	Other Community Leader(s) (fill-in blank below)

National Affiliation:
4-H Afterschool
Boys & Girls Club of America
Junior Achievement
After-School All-Stars
YMCA of the USA
La Petite Academy
Other:

Number of years program has been operating:
under 1 year up to 3 years up to 5 years up to 7 years up to 10 years 10+ years
Number of students in program:
under 100 100-249 250-499 500-749 750-999 1000+
Funding Sources (check all that apply):
21st CCLC
federal government (not 21st CCLC)
state government (not 21st CCLC)
business
local government
foundation/non-profit
program fees

Check the types of activities your program offers:
homework help
sports and recreation
art/drama/dance/music
academic enrichment
literacy/reading
math/science/technology
mentoring
college/career preparation
drug/alcohol/violence prevention
community service
life skills

Where did you hear about Lights On Afterschool!?


*

*-It takes a moment for your registration to be processed, so please do not click the button more than once. A confirmation email will arrive in your mailbox shortly. Thank you!