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 Jessica.Chapman@syhealth.org or visit our website http://www.syhteenclinic.org/health-education
Teacher name *
Your answer
School *
Your answer
Grade *
What class Periods we'll be teaching (include start and finish time for each class period)? *
Your answer
Classroom Location (number) *
Your answer
On average how many students do you have per period? *
Your answer
Your Contact Information *
Your answer
Which curriculum are you using with your students? *
Which lessons from the above curriculum would you like us to present (please list all the lessons below)?
Your answer
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)
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) *
Your answer
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?
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