Registration

First Name:	Last Name:
Organization:
Title:
Street Address:	City:
State:	Zip:
Phone:
E-mail:	E-mail: (again)
Program:	Number of Children in Program:
Select one AAHPERD After School Program Boy Scouts Boys and Girls Club Cyberchase Advisor Museum PBS Station Press Engineer/EWEEK First Lego Girls Inc. Girl Scouts Home School School/Formal Educator Other

Children's Age (check all that apply):
Children under age 5 Children ages 6 - 8 Children ages 9 - 11 Children ages 12 - 14 Children over 14
Grade Level (check all that apply):
Kindergarten	1st Grade	2nd Grade	3rd Grade	4th Grade	5th Grade
6th Grade	7th Grade	8th Grade	9th Grade	10th Grade	11th Grade
12th Grade	College
Setting:		Other: (specify if needed)
Select one After School Program Classroom Large-Scale Events Other (please specify)
I've used Cyberchase in the past I currently use Cyberchase
Now choose a username and password that you will use to login to the Cyberchase Outreach Portal. Username: Password: Re-enter password: