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Name

Address

City

State

Zip

Phone

Alt. Phone

E-mail

If youth please complete:

Age

School

Parent/Guardian Name

Parent's Phone

If adult please complete:

Business Title

Agency

Location

Please check all that apply:

I am registering for myself only
I am registering for myself and other people
Transportation needed	Newsletters/brochures
Enrolling in event	Enrolling in program
I want to volunteer	I want to make a donation
I want to become a partner	I want more information

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• IGNITE L.A.P.S. (Leadership and Abstinence for Positive lifestyleS). Ignite L.A.P.S. is a program that teaches teens the benefits of sexual integrity until marriage. The program is in five phases