Choose Responsibility

Your Name First Name Last Name

Email Address Email Address Confirm Email Address

Address Street Address Street Address 2 City Choose One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Country (if not United States)

I would like to become a [CR] Volunteer. Please send me a Volunteer Pack containing [CR] brochures, bumper stickers, and additional information

I would like to be connected to other [CR] volunteers in my area.

Please let us know if you have any other comments

Which age group do you belong to? Choose One 17 and under 18-20 21-24 25-29 30-39 40-49 50-59 60+

With which of the following groups do you most closely associate? Choose One Student/Under 25 Educator – Primary or Secondary Educator – College or University Parent Military Law Enforcement Healthcare professional None of the above

Which of the following activities would you be interested in doing for [CR]?
(check all that apply)

Write a letter to the editor Hand out materials Start a local chapter Write to elected official Organize an event Raise money Other (Please specify)