Core Elements Higher Education Resource Center: Onsite/Virtual Facilitation Request Form

Core Elements Higher Education Resource Center: Onsite/Virtual Facilitation Request Form

Thank you for your interest in onsite facilitation of the Core College & Career Readiness Program. Please complete and submit the form below.
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*

Area CodePhone Number
High School/Organization Affiliation:*
Role:*

TeacherCounselorPrincipalAssistant PrincipalAdministratorDirectorOther
What type of service(s) are you interested in:*

Year Round Core College & Career Readiness ProgramWorkshops/Webinars for StudentsWorkshops/Webinars for Parents/GaurdiansOther
Who is the audience for this request:*

9th Grade10th Grade11th Grade12th GradeAll GradesParents/Guardians
Please select tentative day(s) the program will be offered:*

MondayTuesdayWednesdayThursdayFridaySaturday
Please select tentative starting time(s) the program/workshop will be offered. Core Elements Higher Education Resource Center is in EST:*

Mornings (Between 8am and 11am)Afternoons (Between 12PM - 3PMLate Evenings (Between 3PM - 6PM)Night (Between 6PM - 8PM)
How did you hear about us?*
Additional Comments:
Should be Empty: