2025-2026 Presentation Request Form Survey

1.School Name:(Required.)

2.School Address: (Required.)

3.Name of Person Completing Form:(Required.)

4.Email of Person Completing Form:(Required.)

5.Alternate Contact Name:
(Back up person just in case you are absent the day of event.)(Required.)

6.Alternate Contact Email:(Required.)

Please provide an estimate of the demographics of students participating in the activity:

7.Provide an estimated percentage:(Required.)

Male

Female

Other

8.Provide an estimated percentage:(Required.)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

9.Age Group:(Required.)

5-9

10-13

14-18

18+

11.Number of People:
(Due to the nature of this activity, class size is limited to 50 people. Please email healthyschools@atlanticare.org to discuss the possibility of adding more students/parents.)
(Required.)

12.Grade Level(s):
(Needed if it is a student presentation.)

13.Room Type/Location:
(Classroom, library, gym, etc.)(Required.)

14.Requested Date:
(Please be as specific as possible to assist with scheduling and list multiple date options. Requests must be made at least 3 weeks in advance.)(Required.)

15.Requested Time:
(Please note start and end time, allowing 45 minutes for this activity.)(Required.)

16.Our presentations require a projector and computer or way for us to connect a laptop.(Required.)

By checking this box, I understand that our school must provide the technology needs listed above.

Thank you for submitting this request. An AtlantiCare Healthy Schools Team member will contact you within 72 hours to discuss the availability of our team and to schedule this activity.