ADMYRE: Advocating for My Relationships Program Request

ADMYRE: Advocating for My Relationships Program Request

Would you like to request ADMYRE for middle school, high school, or college?*

Middle school

High school

College

School Name*

Staff Contact Name*

Staff Contact Email*

Approximately how many students will be in each session?*

(e.g., First Session: 28 students)

Spanish Materials Requested

Yes

How many Spanish-speaking students?

What is the grade(s) of the students in each session?*

(e.g., 9th-10th grades)

What are the class periods and times available to run the program?*

(e.g., 2nd Period: 9:30 a.m. to 11:00 a.m.)

We require a 90-minute time period.

Please let us know what large room is available at your school or facility.*

Examples: library, auditorium, media center, XL classroom (no gyms please)

Will a projector be available for the PIAL staff to use?*

Yes

Will internet be available?*

Yes

Do you have staff available to help facilitate the simulation?*

Yes

How many staff are available to help facilitate the simulation?*

Will a school counselor be available on site for students to talk to?*

Yes

Are there any students with special needs/IEPs and/or aides or paras who will be in the classroom?*

This information helps our facilitators be more aware and sensitive to these needs. If yes, please explain below. If no, please indicate NA.

Are there class dynamics and/or life experiences in any of the class periods that PIAL staff should be aware of?*

This can include any recent student experiences of sensitive topics that may invoke an emotional response. If yes, please explain below. If no, please indicate NA.

Please share any extended breaks you have between now and the school visit. If you do not have any extended breaks, indicate NA.*

Example: March 14-21, 2024

Any other information PIAL staff should know about?

How did you hear about Advocating for My Relationships?

Did someone refer you to PIAL?*

Yes

Name

If you were referred by someone, please list their name, email address and school.

School or Organization

Thank you!

Thanks for choosing PIAL! We look forward to visiting you soon.

SCHEDULE YOUR VISIT: Click "Submit." Then choose a date and approximate start time on our calendar.

You have the option to send yourself a copy of your form's response (below this message) which will include a link to request our PIAL curriculum.

College ADMYRE Request Form: https://app.smartsheet.com/b/form/af620cca9f5a45f0a0cf33fa2d8191c8

Send me a copy of my responses

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