Too Good for Drugs Request for Materials

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

1. Current / Upcoming School Year: *This question is required.

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

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

School Mailing Address: *This question is required.

City / Zip Code: *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 e-mail: *This question is required.

Training Date:
*If implementers have already been trained please list the date in which you are submitting the form as the training date. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Who is providing the training? (first name + last name)

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

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Which school year are you ordering materials for? *This question is required.

Mark which grades will be participating, and include the number of workbooks needed for each participating grade.

Please note you may order one (1) kit per grade and one (1) workbook per student.

Space Cell	# Classrooms	# Workbooks Needed (1 per student)	Kit Needed (Y / N)?
K - Kindergarten	K - Kindergarten: # Classrooms	K - Kindergarten: # Workbooks Needed (1 per student)	K - Kindergarten: Kit Needed (Y / N)?
1st - First Grade	1st - First Grade: # Classrooms	1st - First Grade: # Workbooks Needed (1 per student)	1st - First Grade: Kit Needed (Y / N)?
2nd - Second Grade	2nd - Second Grade: # Classrooms	2nd - Second Grade: # Workbooks Needed (1 per student)	2nd - Second Grade: Kit Needed (Y / N)?
3rd - Third Grade	3rd - Third Grade: # Classrooms	3rd - Third Grade: # Workbooks Needed (1 per student)	3rd - Third Grade: Kit Needed (Y / N)?
4th - Fourth Grade	4th - Fourth Grade: # Classrooms	4th - Fourth Grade: # Workbooks Needed (1 per student)	4th - Fourth Grade: Kit Needed (Y / N)?
5th - Fifth Grade	5th - Fifth Grade: # Classrooms	5th - Fifth Grade: # Workbooks Needed (1 per student)	5th - Fifth Grade: Kit Needed (Y / N)?
6th - Sixth Grade	6th - Sixth Grade: # Classrooms	6th - Sixth Grade: # Workbooks Needed (1 per student)	6th - Sixth Grade: Kit Needed (Y / N)?
7th - Seventh Grade	7th - Seventh Grade: # Classrooms	7th - Seventh Grade: # Workbooks Needed (1 per student)	7th - Seventh Grade: Kit Needed (Y / N)?
8th - Eighth Grade	8th - Eighth Grade: # Classrooms	8th - Eighth Grade: # Workbooks Needed (1 per student)	8th - Eighth Grade: Kit Needed (Y / N)?
High School (Grades 9-12)	High School (Grades 9-12): # Classrooms	High School (Grades 9-12): # Workbooks Needed (1 per student)	High School (Grades 9-12): Kit Needed (Y / N)?
After School Program (no workbooks are needed for this program)	After School Program (no workbooks are needed for this program): # Classrooms	After School Program (no workbooks are needed for this program): # Workbooks Needed (1 per student)	After School Program (no workbooks are needed for this program): Kit Needed (Y / N)?

Mark which grades will be participating, and include the number of workbooks needed for each participating grade.

Please note, you may order (1) one kit per grade on the initial order and (1) one workbook per student on both the initial order and reorders.

Space Cell	# Classrooms	# Workbooks Needed (1 per student)	Product / Item # *Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
K - Kindergarten *Product/Item # is required	K - Kindergarten *Product/Item # is required: # Classrooms	K - Kindergarten *Product/Item # is required: # Workbooks Needed (1 per student)	K - Kindergarten Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
1st - First Grade *Product/Item # is required	1st - First Grade *Product/Item # is required: # Classrooms	1st - First Grade *Product/Item # is required: # Workbooks Needed (1 per student)	1st - First Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
2nd - Second Grade *Product/Item # is required	2nd - Second Grade *Product/Item # is required: # Classrooms	2nd - Second Grade *Product/Item # is required: # Workbooks Needed (1 per student)	2nd - Second Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
3rd - Third Grade *Product/Item # is required	3rd - Third Grade *Product/Item # is required: # Classrooms	3rd - Third Grade *Product/Item # is required: # Workbooks Needed (1 per student)	3rd - Third Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
4th - Fourth Grade *Product/Item # is required	4th - Fourth Grade *Product/Item # is required: # Classrooms	4th - Fourth Grade *Product/Item # is required: # Workbooks Needed (1 per student)	4th - Fourth Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
5th - Fifth Grade *Product/Item # is required	5th - Fifth Grade *Product/Item # is required: # Classrooms	5th - Fifth Grade *Product/Item # is required: # Workbooks Needed (1 per student)	5th - Fifth Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
6th - Sixth Grade *Product/Item # is required	6th - Sixth Grade *Product/Item # is required: # Classrooms	6th - Sixth Grade *Product/Item # is required: # Workbooks Needed (1 per student)	6th - Sixth Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
7th - Seventh Grade *Product/Item # is required	7th - Seventh Grade *Product/Item # is required: # Classrooms	7th - Seventh Grade *Product/Item # is required: # Workbooks Needed (1 per student)	7th - Seventh Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
8th - Eighth Grade *Product/Item # is required	8th - Eighth Grade *Product/Item # is required: # Classrooms	8th - Eighth Grade *Product/Item # is required: # Workbooks Needed (1 per student)	8th - Eighth Grade Product/Item # is required: Product / Item #Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
High School (Grades 9-12)	High School (Grades 9-12): # Classrooms	High School (Grades 9-12): # Workbooks Needed (1 per student)	High School (Grades 9-12): Product / Item #*Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.
After School Program (no workbooks are needed for this program)	After School Program (no workbooks are needed for this program): # Classrooms	After School Program (no workbooks are needed for this program): # Workbooks Needed (1 per student)	After School Program (no workbooks are needed for this program): Product / Item #*Located on the workbook's back cover. Starts with either "A" (elementary, middle) or "HS" (high school) and is four digits long.

Notes: