School/Club Information Form

Returning Club & Team Leader*

Full Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

School District Name*

Shool/Club Name*

Club Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Classroom # *

Open to what grade levels? *

e.g. K-6

For what age range?*

e.g. 5-12

Club Day*

Club Start Time (On Flyer & Website)*

xx:xx AM/PM

Club End Time (On Flyer & Website)*

xx:xx AM/PM

Facility Permit Request Start Time*

Facility Permit Request End Time*

First Date of Club (MM/DD/YYYY)*

Last Date of Club (MM/DD/YYYY)*

Any change to your previous year's club Info? (Date/Time/Classroom#/Phone # on Flyer) *

List ALL Dates of Use (As Per School District Requirement)*

Specify club non-meeting dates (list the dates for your club's actual skipped dates of thanksgiving, winter/spring break, etc.)*

Contact Name on Flyer*

Contact Number on Flyer*

Please enter a valid phone number.

List all confirmed volunteer names*

List all potential volunteer names*

Got questions/comments? Please also provide preferred date(s) for Edeliza to visit, observe and encourage the team.*

Team Leader Info