School Activity Request Form

School Activity Request Form

Middle and High School's ONLY
Name

First NameLast Name
Position
School
County (listed is Southern KY AHEC's Service Region)

BoyleCaseyEstillGarrardJacksonKnoxLaurelLincolnMadisonMcCrearyMercerPulaskiRockcastleWayneWhitley
E-mail*
example@example.com
Phone Number*
GradeAge Group
Number of StudentsAttendees
What type of event

Classroom activityBooth at Health Career FairComing Approx. May 2023 Mega Inflatable Human Body - Take a walk inside the human body to experience the inner workings of various organs (must be inside a gym with a space of 50' long x 30' wide x 12 ' high space) Activities must be related to Health Careers.
What health career program are you interested in?

Karyotyping GeneticsDNA Necklaces/BraceletsBlood TypingAcid-Base LabAmazing Human Body: EKG, Digital Stethoscopes, Organ Models, and FarSight Human Anatomy Interactive Augmented Reality - Must have Wifi!Pharmacy Careers - demonstrationConcussion - Fatal Vision Simulation GogglesTobacco awareness (vaping)Behavioral Health Careers DW Eyes GogglesOptometry Careers - with simulation vision glassesRespiratory Therapy Careers- Simulation IntubationOther
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:

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For Federal Reporting