Join the 15 Minute Child Break

Please select from the following options, all that apply:

I would like to:*

Host an in-person Child Break presentation
Host a Child Break webinar for my school/organization
Participate in a Child Break webinar

I found out about this program:

Word of mouth
Mailing/Email
Past "15-Minute Child Break"

I would like more information:

Please send me more information

Your Information

First Name*

Last Name*

Title

Organization*

Address*

City*

County*

State*

Zip Code*

Work Phone

Fax

Cell Phone*

Email*

Website

Location of presentation (cafe, boardroom, etc.)

Number of Individuals

Time (preference: AM/PM)*

Date

Available space will permit a display for resource materials at the site of the presentation.

Questions & Comments

* Required field

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