Name:
Email Address:
Town:
Select the school where you would like to take action on the Day of Defiance (optional):
BROOKLINE HIGH SCHOOL
CHELMSFORD HIGH SCHOOL
LEXINGTON HIGH SCHOOL
NEWTON NORTH HIGH SCHOOL
NEWTON SOUTH HIGH SCHOOL
Would you like to serve as the Day of Defiance Captain for this school? (optional):
Are you a parent, student, teacher, or activist?
Parent
Student
Teacher
Activist
Phone Number (optional):
AOL Instant Messenger (optional):
Yahoo! Messenger (optional):
Facebook URL (optional):
MySpace URL (optional):
Please enter any additional questions or comments (optional):
