Active Minds Peer-Powered High School Curriculum Request Form

Name of School (No Abbreviations)

School is a:

Name of District

In which state is your district located?

Other State:

School Contact First Name

School Contact Last Name

Email

Role

Title

Is your school a Title I school?

Does your school have an Active Minds Chapter?

What setting do you plan on facilitating the Active Minds Peer-Powered Curriculum?

Other

What grade level(s) do you plan on facilitating the curriculum with (check all that apply):

Approximately how many students will receive the curriculum?