*Last Name:

*First Name:

*Organization:

*Title/Position:

*Mailing Address:

*City:

*State:

- Select State - Alaska Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Louisiana Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip:

*Email:

*Phone:

Information About Your Organization

*What type of organization/location would you like to use the Pool Cool Materials at? (Check the ONE that best fits):

Public Pool (Municpal, Schools, 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

*Where is the swimming pool(s) located? (Check the ONE that best fits):

Outdoor
Indoor
Both

*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+

*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+

*Where did you learn about the POOL COOL Program (e.g. friend, colleague, tv, website, publication, conference)?