JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Role Model Request Form
Fill Out the form below to Request an SD52 Aboriginal Role Model.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Your Name
*
Your answer
School
*
Choose
Lax Kxeen
Pineridge
Roosevelt
Conrad
Port Edward
CHSS
PCS
PRMS
Hartley Bay
Other
Date and time of activity
Your answer
Are you open to alternate dates and times?
Yes
No
Clear selection
Location of Lesson/Activity
Your answer
Which Role Model(s) are you interested in working with?
Your answer
The Role Model may need to connect and or collaborate with you prior to visit. Select the contact info you're willing to share with Role Model.
email
Phone your school
Cell/personal phone number (Provide details below)
Other:
Additional Information (grade/class type, requirements, etc):
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
