SOURCES Elementary Participating School Registry Form 2024-2025

Thank you for your continued participation in SOURCES. KY DBH is dedicated to providing the necessary technical assistance and support to ensure this program is implemented with fidelity on a consistent, year-to-year basis at every school that participates.
The purpose of this form is to identify your school as a participating SOURCES Elementary school. The information collected here will enable your support team at KY DBH and at your Regional Prevention Center to contact you as needed throughout the upcoming school year.
It will also provide student participation rates which are important to maintain the program throughout the state.
All questions are required. Please do not leave anything blank.

1. School Name
Please select your school’s county, then a list of school names will appear. *This question is required.

COUNTY NAME
SCHOOL NAME

2. Regional Prevention Center
Please select your school’s county, then select the Regional Prevention Center (RPC) that appears on the next dropdown. *This question is required.

County Name:
Regional Prevention Center (RPC) Name:

3. Are you planning to implement SOURCES Elementary in your school this year? *This question is required.

Your reply will be recorded when you hit the Submit button below. Thank you for your response.

4. Your Name: *This question is required.

4. Your Email: *This question is required. This question requires a valid email address.

4. Your Phone Number with Area Code: *This question is required.

4. Are you the SOURCES Elementary Coach for your school? *This question is required.

4. In the grid below, for each grade that will be learning SOURCES Elementary at your school, please mark the number of classrooms per grade and the anticipated number of students per grade.
All blanks must be filled in with a number. Please use "0" where appropriate. *This question is required.

Space Cell	# Classrooms Per Grade	# Anticipated Students Per Grade
K - Kindergarten	K - Kindergarten: # Classrooms Per Grade	K - Kindergarten: # Anticipated Students Per Grade
1st – First Grade	1st – First Grade: # Classrooms Per Grade	1st – First Grade: # Anticipated Students Per Grade
2nd – Second Grade	2nd – Second Grade: # Classrooms Per Grade	2nd – Second Grade: # Anticipated Students Per Grade
3rd – Third Grade	3rd – Third Grade: # Classrooms Per Grade	3rd – Third Grade: # Anticipated Students Per Grade
4th – Fourth Grade	4th – Fourth Grade: # Classrooms Per Grade	4th – Fourth Grade: # Anticipated Students Per Grade
5th – Fifth Grade	5th – Fifth Grade: # Classrooms Per Grade	5th – Fifth Grade: # Anticipated Students Per Grade
6th – Sixth Grade	6th – Sixth Grade: # Classrooms Per Grade	6th – Sixth Grade: # Anticipated Students Per Grade

4. How many adults at your school are involved in teaching the SOURCES curriculum to students? *This question is required. This question requires a valid number format.

4. Are you training any new SOURCES instructors at your school this year? *This question is required.

4. Training date (of the new SOURCES instructors at your school): *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Number of instructors trained? *This question is required. This question requires a valid number format.

4. What is the anticipated start date of SOURCES at your school? *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. Do you need any Technical Assistance before Implementation? *This question is required.

4. Who is your school’s SOURCES Elementary Coach?
If you are your school's coach, please write "self".
If you do not know the answer, please write NA on the line below and continue to the next question. *This question is required.

4. What is your school’s SOURCES Elementary Coach’s email address?
If you are your school's coach, please write "self".
If you do not know the answer, please write NA on the line below and read the instructions below. *This question is required. This question requires a valid email address.

If you are unable to provide contact information for your school’s SOURCES Elementary Coach for any reason please contact Sheila Barnard (sheila.barnard@ky.gov) or Jean Johnson (jean@reacheval.com).