Chapter Interest Form

First Name

Last Name

Phone

Graduation Year (if applicable)

If you are a faculty, staff or administrator, what is your title?

School Name (no abbreviations)

ex: University of California, Los Angeles (not UCLA)

School Street Address

School City

School State/Province

School Zip/Postal Code

Enter "other" State/Province here:

School Details

Is your school a (select all that apply):

Four-year college or universityMinority-serving college or universityCommunity CollegeHigh School

How did you hear about Active Minds?