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 2-3 business days.Should you have any questions please contact Jessica Chapman at
or visit our website
Please make sure you submit your request at least 2 weeks prior to the requested presentation date.
What class periods/times is this presentation(s) for? (include start and finish time for each class period)
Classroom Location (number):
On average how many students do you have per class period?
Your Contact Information (phone and e-mail):
Which topic(s) would you like us to cover? (Please note we can only cover one topic per day)
Gender, Gender Identity and Gender Stereotypes
The Reproductive System: Anatomy and Physiology
Sexually Transmitted Infections (STIs)* (Students need to have a basics understanding of Anatomy prior to presentation of this topic)
Contraceptive Methods* (Students need to have a basics understanding of Anatomy prior to presentation of this topic)
Healthy Relationships and Sexual Assault
Human and Sex Trafficking
Would you like the above presentation(s) to come from the district approved curriculum (Advocates for Youth 3 R's Curriculum)?
Would you like us to facilitate an on-going group ?
If you would like us to facilitate an on-going group which of the below would you like?
Girls Empowerment Group Ages 12-24 (5-10 weeks)
Boys Group Ages 12-24 (5-10 weeks)
Please list the 3 dates you would prefer for us to present below (1-3): (Please note that due to time constraints, we will not be able to provide health education during minimum days)
In order for us to effectively teach your students, we would like to know what discussions you've already had regarding reproductive health. What topics (if any) have you already taught your students?
Reproduction (how a pregnancy occurs)
HIV Transmission and Prevention
Birth Control Methods
Coercion and Consent
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