1. Organization / Contact Information

* Indicates a required field

School District:
What if my disitrict/school is not listed?
School / Organization:
* First Name:
 Enter First Name
* Last Name:
 Enter Last Name
* Address:
 Enter Address
* City:
 Enter City
* Zip Code:
 Enter Zip CodeEnter Zip Code
* County:
 Enter County
* Phone:
 Enter PhoneEnter Phone
* Email:
 Enter Email AddressEnter Email Address

2. Purpose of Request

IMPORTANT:  Please submit a separate form for each phase. A confirmation email will be sent once we receive a request for each phase.



(Event Takes Place At Address In Block 3)
Phase II
(7th Grade) - Outdoor Ropes Course
(Volk Field or Sussex Course ONLY)
Phase III
(9th Grade) - Leadership Development Course
(Volk Field or Sussex Course ONLY)

 

3. Event Information

IMPORTANT: Unless specific dates and session times are listed, request will not be processed. Please make sure to check our online calender to avoid conflicts.

Please enter the event address if your requesting a Phase 1 event

Ensure the number of participants are between 30 and 70 students:
Start Time
End Time
# of Participants
* Session 1:

Session 2:
T
Time
#

Need To Add An Alternate Day?   Click Here
Start Time
End Time
# of Participants
Session 1
Session 2
#

4. Drug and alcohol education and prevention curriculum / instruction

Learning Objectives: (Select all that apply)

Safety

Fairness

Choices

Peer Pressure

Team Building

Role Models

Leadership

Honesty

Integrity

Consequences

Responsibility

Self Control

Delayed Gratification

Invalid format. Hours of classroom instruction participants will receive regarding drugs and alcohol this school year?

 

 

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