Survey - Outreach Program Request Form 2019-2020

*1.

Question - Required - Your First and Last Name:

*2.

Question - Required - School Name:

*3.

Question - Required - Grade Level:

*4.

Question - Required - Is your school Title 1?

*5.

Question - Required - Students per Class:

*6.

Question - Required - Preferred Month(s):

*7.

Question - Required - Preferred Day(s) of the Week:

*8.

Question - Required - Preferred Start Time:

*9.

Question - Required - Do you prefer lessons delivered in consecutive weeks or months?

*10.

Question - Required - Your Email Address:

*11.

Question - Required - Your Phone Number:

*12.

Question - Required - School District:

*13.

Question - Required - School Address:

*14.

Question - Required - School Year Start and End Dates:

*15.

Question - Required - Please review our outreach lesson topics and select the three you would like to receive.
Please make between 1 and 3 selections from the choices below.

	Animal Shelters & Adoption
	Responsible Pet Care
	Dog Safety & Body Language
	Pet Overpopulation
	Nurturing Empathy & Compassion for Animals
	5 Freedoms of Animal Welfare
	Animal Shelter Careers
	Wonders of Local Wildlife: Coexisting Together
	Plastic Pollution and Animals
	Food Choices and the Environment
	Character Trait: Empathy
	Character Trait: Caring
	Character Trait: Citizenship
	Character Trait: Integrity
	Character Trait: Kindness
	Character Trait: Perseverance
	Character Trait: Respect
	Character Trait: Responsibility

*16.

Question - Required - Please list the classes (including your own) you would like us to visit. Include the teachers' names, grades, room numbers, and outreach lesson topics if different.

17.

Question - Not Required - Please list any other class, school, or community topics or issues you would like to see addressed during your lessons (if not included above.)

18.

Question - Not Required - Please provide any additional information that is important for us to know about your class or school, including parking issues or school closure dates that would impact scheduling.