PSEG Long Island - High School Program - I Am EM-Powered Program Registration

PSEG Long Island - High School Program - I Am EM-Powered

Program Registration Form
What is your role? *

Teacher Administrator Other
If role is "other" please include your title
Full Name *

First Name Last Name
County *

Suffolk Nassau Rockaways
School District *
School Name (only answer if you are a teacher)
School Street Address *
Town, State, Zip *
School Phone and Extension *
Cell Phone Number
Please enter a valid phone number.
School Affiliated E-mail address *
example@example.com
What grade level will you use program? *

9th 10th 11th 12th
How many of your classes will participate in this program? *
How many students will be participating (based on your number of classes participating)? *
What is the best way to contact you?

Email School Phone Cell Phone Text Message to Cell Phone (please be sure to include your cell phone number above)
Comments or Questions
Should be Empty: