New School Interest Survey

Type of School

What district is your school located in?

Which school do you represent?

What is your school’s address?

Funding/ Supportive Services

Are you currently receiving funding or supportive services from WayneRESA and the TRAILS model?

Point of Contact Name

Who is the best point of contact for the School Success Initiative at the school you represent?

Point of Contact Title

Point of Contact Phone

Phone

Point of Contact Email

Best Time to Reach Point of Contact

School Success Initiative Representative

Have you already been contacted by a School Success Initiative representative?

DWIHN’s School Success Initiative

Are you interested in participating in DWIHN’s School Success Initiative?

Risk Factors

Have you noticed any concerns amongst your students regarding the following risk factors?

Additional Comments

Contact Information

First Name

Last Name

Phone

Position/Title

Send me a copy of my responses