Program Interest Form

Program Interest Form

Thank you for your interest in Planned Parenthood Mar Monte's Education Programs! Please complete this form to let us know which programs and services you'd like to learn more about.

PPMM Education Programs:

* PPMM Sex Ed: Online courses for middle and high school students, aligned with the California Healthy Youth Act (CHYA).

* Sex Ed Kits: Submit this form to request a kit for your site. Kit options include:

STI and unintended pregnancy prevention tips
Communication tips
Birth control and sexual health care access info
Condoms OR period products
Stickers or other fun items (if available)

* Volunteer Opportunities: Become a peer educator or youth designer.

* Community Partnerships:

Enlaces Promotores Program (Spanish-speaking volunteers)
Evidence-based sex education for juvenile justice and child welfare systems
Mental Health First Aid training
Sex Ed Outreach Kits

First Name:*

Last Name:*

Organization or School Name*

Please write out the full name of your organization - do not use acronyms.

Email*

Phone #*

Phone

Extension:

(If applicable)

City*

County*

Select the County where you mainly operate out of or want to implement PPMM programs.

Select

County (write in)*

Please write in your county.

Zip Code*

Program(s) I'm interested in:*

Select

Did your school/district/site receive PPMM eCourses last year?*

Yes

Not Sure

Program language needed:*

Select

Desired Start Date*

Please enter the date you want the course to begin.

Sex Ed Requests: Reminder- CHYA requires parents be notified at least (2) weeks prior to Sex Ed eCourse start date.

NON-Sex Ed Requests: Please enter the date of your event or other important date related to your request.

TOTAL Estimated # Participants:*

Comments and Questions

Systems-Involved Youth?

We're seeking partners to co-implement evidence-based programs. Complete this form & we'll reply within 48 hours. Thank you!

Sex Ed Kits

Submit this form to request a kit for your site.

Send me a copy of my responses

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