School Activity Request Form

School Activity Request Form

Middle and High Schools ONLY
Name

First NameLast Name
School
Position
County (listed is Southern KY AHEC's Service Region)
E-mail
example@example.com
Phone Number
GradeAge Group
Number of StudentsAttendees
What type of event
What health career program are you interested in? (All programs are for in-class 35 students max)

Other
How long is your class period?
Potential dates you are looking at (please list at least two)
For Federal Reporting
How many Caucasian Student in the class/group
How many African American Students
How many Asian Students
How many Hispanic Students
Race is not reported
Should be Empty:

For Federal Reporting