<%@LANGUAGE="VBSCRIPT"%> Web-Based Materials Registration
POOL COOL Sun-Safety Program
Web-Based Materials Registration
         
CONTACT INFORMATION
Please fill out all fields, including Email. Information will be used for program purposes only.
     
Last Name: First Name:
Organization: Title/Position:
Mailing Address:
  Street Number, Street Name, Apt/Suite Number
City: State: Zip:
Email: Phone: Fax:
         
INFORMATION ABOUT YOUR ORGANIZATION
         
1. What type of organization/location would you like to use the Pool Cool Materials at?
(Check the ONE that best fits):
Public Pool (Municipal, School, etc.)
Private Pool (Country Club, Fitness Club, YMCA, HMA, etc.)
Backyard Pool
School Classroom
Church
Recreation Center
Camp or Club organization (Girl Scouts, etc.)
Other    Please specify
  
2. What is the age group of the kids you would like to use the materials with?
(Check all that apply):
3-5
5-10
10-15
15+
 
3. Approximately how many children do you anticipate being exposed to the materials?
(Check the ONE that best fits):
0-10
10-50
50-100
100+
   
4. Where did you learn about the POOL COOL Program (e.g. friend, colleague, tv, website, publication, conference)?
 
   

 

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©2012 Pool Cool Program, All Rights Reserved
Rollins School of Public Health, Emory University
1518 Clifton Rd. NE Room 524, Atlanta, GA 30322
Phone: (404) 727-7589, Fax: (404) 727-1369
For technical problems with this site please email: poolcool@sph.emory.edu