School Activity Request Form

School Activity Request Form

Middle and High Schools ONLY
Name

First NameLast Name
School
Position
County (listed is Southern KY AHEC's Service Region)

BoyleCaseyEstillGarrardJacksonKnoxLaurelLincolnMadisonMcCrearyMercerPulaskiRockcastleWayneWhitley
E-mail*
example@example.com
Phone Number*
GradeAge Group
Number of StudentsAttendees
What type of event

Classroom activityBooth at Health Career FairMega Inflatable Human Body (200 students minimum required) - Take a walk inside the human body to experience the inner workings of various organs (must be inside a gym with a space larger than 50' long x 30' wide x 12 ' high space) Activities must be related to Health Careers.
What health career program are you interested in? (All programs are for in-class 35 students max)

Karyotyping GeneticsDNA Necklaces/BraceletsBlood TypingAcid-Base LabAugmented Interactive Anatomy - Must have Wifi!Pharmacy Careers - demonstrationConcussion - Fatal Vision Simulation GogglesTobacco awareness (vaping)Behavioral Health Careers DW Eyes GogglesOptometry Careers - with simulation vision glassesRespiratory Therapy Careers- Simulation IntubationOther
How long is your class period?
Potential dates you are looking at (please list at least two)
For Federal Reporting
How many Caucasian Student in the class/group
How many African American Students
How many Asian Students
How many Hispanic Students
Race is not reported
Should be Empty:

For Federal Reporting