EmailMeForm
The 84 Chapter Registration and Renewal Form
(2019-2020)
School/Organization Name
*
Who is your sponsoring school/organization?
Chapter Name:
What is your official group name?
Today's Date
*
MM
/
DD
/
YYYY
School or Community Organization?
*
School
Community Organization
How did you hear about The 84?
*
Please Select
Returning Chapter
The 84 website
The 84 Staff Members
Cold Call
Facebook
Friends/peers
Local Tobacco Control Program
Flyer
Other
Returning Chapter
Other (please explain):
Address (Where you would like to receive materials from The 84):
*
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Adult Advisor #1 Name
*
First
Last
Adult Advisor #1 Email
*
Adult Advisor #1 Phone
*
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-
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-
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Adult Advisor #2 Name
First
Last
Adult Advisor #2 Email
Adult Advisor #2 Phone
###
-
###
-
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Youth Leader Contact Information (They will receive the latest updates from The 84)
Youth Leader #1 Name
Youth Leader #1 Email
Youth Leader #2 Name
Youth Leader #2 Email
Number of youth expected in your chapter
*
Please write an updated description (3-5 sentences) about your group. (This will go on your Chapter's page on The 84 website)
If your Chapter has any social media platforms (ie. Twitter, Facebook, Instagram) please list your handles so we can connect with you.
Does your school/organization have a photo release policy? (If you answer "no," you will need to submit a photo release to The 84 staff for everyone involved in your Chapter.)
*
Yes
No
FOR SCHOOLS ONLY: Did you get approval from your school principal to be an 84 Chapter in 2019-2020? (Approval is required)
Yes
No
Electronic signature of adult advisor (enter full name as electronic signature):
*