| Last Name |
* |
|
| First Name |
* |
|
| Title |
|
|
| School/Organization/Other |
* |
|
| School District Name |
|
|
| School District Number |
|
|
| Street Address |
* |
|
| City |
* |
|
| Zip Code |
* |
|
| Phone Number |
* |
Extension:
(numbers and dashes only i.e. 312-123-4567) |
| Fax Number |
|
|
| e-mail Address |
* |
(All correspondence regarding this program will be e-mailed to this address.) |
| Password |
* |
(DON'T use a password that you use on your school's computer system or anyplace else. The password will be required to enter your votes on Election Day.) |
| Number of Students Participating |
* |
(If you're registering your own classroom, enter the number of pupils you have. If you're registering for multiple classrooms or the whole school, please enter the approximate total number of students. This number is only used to give us an idea of the number of students participating and has no bearing on the number of votes you submit on Election Day.) |
| What is/are the grade level(s) of these students? |
* |
(At least one grade level must be checked) |