Educational Presentation Request

We will fulfill educational requests dependent upon availability. Once your submission is complete, one of our staff will be in touch with you to confirm your request.

Date

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Name of School/Organization*

For the following section, please provide as much class information as possible AND select a Lesson Topic. The first table is for reproductive health topics and the second table is for other public health topics such as ticks & lyme disease or oral health, etc.

Reproductive Health Lessons (Please select one or more educational presentations per class period - each lesson requires one full class period)

Rows	Days of the week this class meets (please type in each day)	Class start time and end time	Number of students	High School or Middle School	Lesson 1 Topic	Lesson 2 Topic	Lesson 3 Topic	Lesson 4 Topic	Check if testing is required.	Are there any topics that should not be discussed in this lesson? Please describe.
Class Period/Group 1
Class Period/Group 2
Class Period/Group 3
Class Period/Group 4
Class Period/Group 5

Public Health Lessons (Please select one or more educational presentations per class period - each lesson requires one full class period)

Rows	Days of the week this class meets (please type in each day)	Class start time and end time	Number of students	Grade Level	Lesson 1 Topic	Lesson 2 Topic	Lesson 3 Topic	Check if testing is required.
Class Period/Group 1
Class Period/Group 2
Class Period/Group 3
Class Period/Group 4
Class Period/Group 5

Please let us know any other necessary information about your classes; such as what month or specific date you would like lessons to be scheduled, technology available, etc. Or type NA.*

Clinical Services (Learn more about what our clinic offers such as Immunizations, Physicals, Reproductive Health Services and more)Environmental Services (Learn about the many services offered by Environmental Health such as Septic Testing, Water Testing, Food Permitting, Rabies Control, etc.)Children's Services (Learn more about Early Intervention, Pre-School Programs, Children/Youth with Special Healthcare Needs)

Please describe any special considerations for participants

Ex: One-on-One Assistance, Visually Impaired, Hearing Impaired Etc.

Please verify that you are human*