Planning Form
Name
*
First Name
Last Name
Enter your email
*
example@example.com
School Name/ Number Ex: PS94Q
*
Cycle
*
1
2
3
Multi
Summer
Select one:
*
In-School
After-School
Grade Level/ Age
*
Title of Residency
*
How many sessions total
*
Session Date 1
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Session Date 2
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Session Date 3
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Session Date 4
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Session Date 5
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Will there be a culminating event? (You will be asked to confirm this by week 6)
*
Yes
No
TBD
Enter the date of Culminating Event
/
Month
/
Day
Year
Date
Time of Culminating Event
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
How many classes will you be teaching?
*
Enter the following information for your first class:
*
Enter the following information for your second class:
*
Enter the following information for your third class:
*
Enter the following information for your forth class:
*
Enter the following information for your fifth class:
*
Enter the following information for your sixth class:
*
Enter the following information for your seventh class:
*
Enter the following information for your eighth class:
*
Enter the following information for your ninth class:
*
Enter the following information for your tenth class:
*
Enter the following information for your eleventh class:
*
Enter the following information for your twelfth class:
*
Residency Notes & Safety Protocol:
Save
Submit
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