First Name*	Last Name*
Organization Name
Address	Address 2
City	State (2-letter code)
Postal Code*	Country
Phone	Mobile Phone
Email*	Website
Twitter	Facebook

Which of the following topics most interest you?
(Select all that apply)

	Play
	Playwork
	Education
	Early Childhood
	Screen Time and Technology
	Decade for Childhood
	Advocacy

Which of the following categories best describe you?
(Select all that apply)

	Educator: 0 to 3 years
	Educator: 3 to 8 years
	Educator: Grade 4 to Grade 12
	Educator: Higher Education
	Educator: Informal or Nonformal
	Program or Other Administrator
	Nonprofit leader
	Child Care Provider
	Psychologist or Psychiatrist
	Health Care Professional
	Business or Industry Representative
	Foundation Representative
	Elected Official
	Parent
	Grandparent
	Other

Which of the following volunteer activities most interest you?
(Select all that apply)

	Outreach to elected officials – state/local
	Outreach to elected officials – federal
	Writing op-eds, letters to the editor, editorials or other media pieces
	Distributing Alliance information at gatherings/meetings
	Hosting community discussions/events
	Hosting an Alliance display at events
	Serving as a program/content area advisor
	Participating on an Alliance committee
	Helping with Alliance fundraising activities
	Other

Which of the following advocacy activities most interest you?
(Select all that apply)

	Send an e-mail or letter to an elected official
	Call the office of an elected official
	Meet with a legislative aide or elected official in your congressional district
	Meet with a legislative aide or elected official in Washington, D.C.
	Speak or ask a question at a Town Hall meeting or other event
	Write and submit an op-ed piece
	Write a letter to the editor of a newspaper or other publication
	Host a media event
	Participate in a radio interview
	Participate in a TV interview
	Other