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REQUEST TO START A CHAPTER

Please complete this form if you are interested in starting a Project Eye-To-Eye Chapter at your school or in your local community. Project Eye-To-Eye looks forward to working with you in completing the process to empower your LD/ADHD community.

No information should be submitted to or posted on the Project Eye-To-Eye Web Site by users under 13 years of age without the consent of their parent or guardian.

Your Contact Information

Please select the category that best describes you (voluntary).
Student Family Member Other:
Educator   Professional  
Your First Name: Your Last Name:
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City: State/Province/Region:
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Email Address: Telephone Number:

Sponsoring College or High School Contact

Please provide the name and address of your contact at the local college or high school interested in sponsoring a Project Eye-To-Eye Chapter and helping Project Eye-to-Eye in recruiting mentors. Leave this section blank if you do not have a school contact.

First Name: Last Name:
Mailing Address (Line 1): Mailing Address (Line 2):
City: State/Province/Region:
Postal/Zip Code: Country:
Email Address: Telephone Number:

Community School Contact

Please provide the name and address of of the teacher, school administrator, or other individual at a community elementary, middle or high school, preferably near the college or high school, who can help connect Project Eye-To-Eye to students to mentor. Leave this section blank if you do not have a community school contact.

First Name: Last Name:
Mailing Address (Line 1): Mailing Address (Line 2):
City: State/Province/Region:
Postal/Zip Code: Country:
Email Address: Telephone Number:

Project Eye-To-Eye Programming Model Principles

I have read and agree to follow Project Eye-To-Eye's Programming Model Principles.