Register your school to participate in the School & Youth^SM Programs by filling out and submitting the form below. The Leukemia & Lymphoma Society (LLS) will contact you shortly to confirm your registration and provide you with more information.

Because we are COPPA compliant, only school administrators and students over 14 may submit their school.

*required fields

First Name*
Last Name*
Your Title
School Name*
School Address*
City*
State/Province*	Choose a State/Province Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland And Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip/Postal Code*
Day Phone
Fax
Email*
Preferred Method of Contact*	EmailPhone

We are interested in participating in the following program: (Please note your local LLS Chapter may not offer all programs)* Pennies For PatientsPasta For Pennies (limited markets)HOP for Leukemia & Lymphoma (limited markets)Other

We would like to run the program on the following dates (recommended: a 3 week period in January, February or March)*

How did you hear about our School & Youth Programs

BrochureFaxFriendLetterOther

Our school has a student currently in treatment for a blood cancer. Please contact me with more information about the Trish Greene Back To School Program.

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