Register as an Adult Advisor

Step 1 > Step 2 > Step 3

*First Name
*Last Name

*Home Mailing Address
*City
*State
ChooseAKALARASAZCACOCTDCDEFLFMGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPWRISCSDTNTXUTVAVIVTWAWIWVWY *ZIP

Mobile Phone Number
*Email

*T-Shirt Size Choose X-Small Small Medium Large X-Large 2X-Large 3X-Large 4X-Large 5X-Large 6X-Large

*Birthday

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Accept text messages for timely alerts
Accept email messages for timely alerts

* Required

Step 1 > Step 2 > Step 3

*Crew Name
(What would you like your crew/club to be called?)
*County
Choose Barbour Berkeley Boone Braxton Brooke Cabell Calhoun Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Jefferson Kanawha Lewis Lincoln Logan Marion Marshall Mason McDowell Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas Ohio Pendleton Pleasants Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood Wyoming *Crew Type
Choose Community School

*Organization Name
(Who is your crew/club affiliated with? i.e. school name, community group, church, etc.)
*Organization Address
*City
*State
ChooseAKALARASAZCACOCTDCDEFLFMGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPWRISCSDTNTXUTVAVIVTWAWIWVWY *ZIP

* Required

Step 1 > Step 2 > Step 3

1. *Describe your experience working with youth.
   
2. *Describe previous tobacco prevention work or discuss your interest in becoming involved in youth tobacco prevention.
   
3. *Briefly describe you and your organization's capacity to maintain a RAZE Crew (where will you hold meetings, organizational support, teen recruitment plan, etc.).
   

* Required