Teen Clinic Health Education Request Form
This form is for teachers who would like to host our health education team at your school site. Options are on a first come first served basis and we will only be able to go to two classes each day. Please fill out the form below and we will get back to you in the next 1-2 business days. Should you have any questions please contact Jessica Chapman at
or visit our website
What class Periods we'll be teaching (include start and finish time for each class period)?
Classroom Location (number)
On average how many students do you have per period?
Your Contact Information
Which curriculum are you using with your students?
3 R's Advocates for Youth
Not a specific lesson from a curriculum (please list topics you would like below)
Which lessons from the above curriculum would you like us to present (please list all the lessons below)?
If you do not need us to implement a specific lesson in a curriculum which topic(s) would you like us to cover? (Please note we can only cover one topic per day)
The Reproductive System: Anatomy and Physiology
Sexually Transmitted Infections (STIs)
Nutrition and Fitness
Gender, Gender Identity and Gender Stereotypes
HIV Prevention and Speaker
Puberty and the developing body
Human and Sex Trafficking
Girls Empowerment Group (10 week course)
Fit and Healthy Group ( 8 week course)
Please the 3 dates you would prefer for us to present below (1-3): (Please note that unfortunately due to time constraints, we will not be able to provide health education during minimum days)
Before we go in your classroom to present the topic or lesson you have requested for us to teach have you taught the students any of the below topics?
Reproduction (how a pregnancy occurs)
HIV Transmission and Prevention
Birth Control Methods
Coercion and Consent
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