First Name:   Last Name:  

Please check the box(es) that describe you:

PTA member    Parent     Dietician     School Nurse    Other Health Care   Student    

Educator Parks & Rec   Walking/Biking Advocate  Other

Home Address: Note: We need your home address to place you in the right team for your legislative visits. We will not share or sell this information.

City:          County: Select One Alameda Alpine Amador Butte Calaveras Colusa Contra Costa Del Norte El Dorado Fresno Glenn Humboldt Imperial Inyo Kern Kings Lake Lassen LosAngeles Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Orange Placer Plumas Riverside Sacramento San Benito San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Stanislaus Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba

Zip:

Phone:

Fax:

EMAIL:  

Please contact me about being the team leader for one or more legislative visits.

Check here if you have a child in a K-12 school in California.

If you'd like to have information about nutrition at your child's school for ENACT 2005, please write in the name of the school(s) here: