SOURCES Elementary Request for Materials Form

Please complete one (1) request PER school, do not combine orders for multiple schools.

2. Regional Prevention Center (RPC):
Select your school's county first, then select the RPC Region that is shown in the next dropdown.

County Name:
Regional Prevention Center (RPC) Name:

3. School Name:
Select your school's county first, then select your school name from the second drop down menu that appears.
If your school name is not on the list, proceed to the next question.

COUNTY NAME
SCHOOL NAME

4. If your school's name was not listed above please mark the checkbox below. Otherwise, leave the checkbox blank and proceed to the next question.

My school's name was not listed above.

Enter your full school name without any abbreviations. *This question is required.

School Mailing Address: *This question is required.

City / Zip: *This question is required.

School District: *This question is required.

School Contact (first + last name): *This question is required.

Contact Person's Title: *This question is required.

Contact Person's Phone (xxx-xxx-xxxx): *This question is required.

Contact Person's E-mail: *This question is required. This question requires a valid email address.

Who are the trained coaches in your school? If you are the trained coach, write "Self". *This question is required.

Coach's Contact E-mail: *This question is required. This question requires a valid email address.

Approximate implementation date (mm/dd/yyyy): *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Is this an initial order or reorder? *This question is required.

Mark which grades will be participating, and include the number of classrooms and students in each grade. Student counts can be approximate.

Space Cell	# Classrooms	# Students per Grade (approx.)
K - Kindergarten	K - Kindergarten: # Classrooms	K - Kindergarten: # Students per Grade (approx.)
1st - First Grade	1st - First Grade: # Classrooms	1st - First Grade: # Students per Grade (approx.)
2nd - Second Grade	2nd - Second Grade: # Classrooms	2nd - Second Grade: # Students per Grade (approx.)
3rd - Third Grade	3rd - Third Grade: # Classrooms	3rd - Third Grade: # Students per Grade (approx.)
4th - Fourth Grade	4th - Fourth Grade: # Classrooms	4th - Fourth Grade: # Students per Grade (approx.)
5th - Fifth Grade	5th - Fifth Grade: # Classrooms	5th - Fifth Grade: # Students per Grade (approx.)
6th - Sixth Grade	6th - Sixth Grade: # Classrooms	6th - Sixth Grade: # Students per Grade (approx.)

Notes: