TechREACH: Role Model

Interest Form

*First Name	*Last Name



*Address



*City	*State	*Zip Code (xxxxx):



*E-Mail	*Phone (xxx-xxx-xxxx):



*Employer	*Position



*How did you hear about TechREACH?



*Please indicate the amount of time you can contribute to this volunteer opportunity:




Please check any available resources you have to offer a TechREACH club:
Field trip opportunities	Hands-on activities for students
Identifying guest speakers	Career exploration activities
Other:


*Please write one to two sentences describing why you are interested in being a TechREACH Role Model.



Do you know someone who might be interested in being a role model? Enter their name and e-mail address below and we'll let them know you recommded them. You can submit multiple e-mail addresses by seperating them with a comma.
E-Mail Address(es)