Your name: Your email address: Do you plan to: (check all that apply) Run the program yourself Conduct training workshops to train afterschool program leaders to run the program When do you plan to run the program (or training workshop)? How do you, or the people you train, plan to run the program: (check all that apply) Afterschool program in a school Afterschool program in a community-based organization Summer camp Science club Other (please specify): Institution(s) where this program will be implemented (please include city and state): Zip Code: Grade level(s) expected to participate in the program: Number of anticipated participants: Training: I have already been trained. Please provide name of trainer and date/location of training: I request a waiver from training. Please provide reason for request of waiver: Additional information you would like to provide:
