From The Heart School Participation Form

Welcome to From the Heart School Program

Please provide the following information so we can support the From the Heart program at your school. Once I receive your information I will verify your dates for presentations and wheelchair reservations.

School*
(choose from the dropdown list)
District*
Coordinator's Name*
First Last
Coordinator's Email*
Coordinator's Phone #*
Secondary Contact Name
First Last
Secondary Contact Email Address
Secondary Contact Phone Number
Third Contact Name
First Last
Third Contact Email Address
Third Contact Phone Number
Semester*
Preferred Kick Off Date*
MM slash DD slash YYYY
Second Choice Kick Off Date*
MM slash DD slash YYYY
Would you like a presenter for your Kick Off?*
What audience would receive this presentation?*
if other*
Can you provide audio / visual equipment?*
Projector, PA System, etc. (laptop will be provided by the presenter.)
Preferred Wheelchair Reservation Date*
Choose The Week of:
Second Choice of Wheelchair Reservation Date*
Choose The Week of:
Are you interested in the FREE field trip to the Blackhawk Museum?*
To qualify, your school must raise an average of $1.50 per student.
Indicate the quantity of supplies you will need:*
Canisters / School Buses for Collection Posters
Any suggestions on how we can support your school?
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From The Heart School Participation Form

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