Girls' Program Sign Up Form

If you are interested in the Get In Touch Girls' Program and would be happy to host a "GIT Your Pink On!^®" Day at your school, please fill out the form below and we will get back to you very soon. You can host your "GIT Your Pink On!^®" Day any day that is convenient for you and your organization. Thank you so much for your interest.

NOTE: If you are not a school, please use the Daisy Wheel^® order form.

Fields with an * are required.

Please note: Allow 4 to 6 weeks for delivery of the wheels.

*First Name
*Last Name
*Title
*School Name / Organization
*Street Address
Address Line 2
*City
*State / Province / Region
*Postal / Zip Code
*Country
*Phone
*Email
*How did you hear about Get In Touch?
If "Other", please describe.
*Do you agree to host a "GIT Your Pink On!^®" Day to help us fund this program?	I agree
*Do you agree to sending us the Program Evaluation?	I agree
Comments
Daisy Wheels:
Number of Daisy Wheels required	(ex. 250)
Grade Level(s)
Estimated date of use	(mm/dd/yyyy)
Please allow 4 to 6 weeks for delivery of the wheels. Each year, at the same time, we will send the same number of Daisy Wheels, unless you tell us differently. We'll also send you a reminder a month ahead.

Please enter the words below.