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 Jessica.Chapman@syhealth.org or visit our website http://www.syhteenclinic.org/health-education
Please make sure you submit your request at least 2 weeks prior to the requested presentation date.
Teacher name *
Your answer
School *
Your answer
Grade *
What class periods/times is this presentation(s) for? (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 class period? *
Your answer
Your Contact Information (phone and e-mail): *
Your answer
Which topic(s) would you like us to cover? (Please note we can only cover one topic per day)
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?
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) *
Your answer
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?
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