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EcoHealth Program Interest Form 2026
1.
First and Last Name
2.
Email
3.
Phone Number (best number to reach you the day of the event)
4.
School Name
5.
School District
6.
Grade (select all that apply)
Elementary
6th
7th
8th
9th
10th
11th
12th
7.
I am requesting a:
Classroom Presentation
Career Day Presentation
Public Health Simulation in class
Informational Table at school event (e.g., Career Day, Open House)
Parent Presentation (e.g., Coffee with the Principal, PTA)
8.
Subject
Biology
Environmental Science
Anatomy/Physiology
Career Day
General Mosquito Information
Other (please specify)
9.
Preferred date for presentation (We are unavailable on Fridays)
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
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30
31
10.
Back up date for presentation (We are unavailable on Fridays)
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
11.
Any other information you'd like to provide about the request?
12.
Would you like to be added to our quarterly newsletter for educators and school staff? The newsletter provides information on current EcoHealth offerings, mosquito toolkits for schools, and local vector updates.
Yes
No
Send me a copy of my responses via email