Name of School:
Address:
Contact Person:
Phone Number:
E-mail:
Current Provider (if applicable):

Please enter a general description of your school that you would like to include in the Letter of Invitation to Healthcare Providers:

What are your school hours, please include after school program hours if apply:

Needs / Wants List:

Location of services offered:

Onsite
School linked

Hours of operation desired:

Full-time service
Part-time service

Hours:

School hours
Extended hours*

*If there are extended hours, please give days and hours of extended hours:

Describe the type of health services your school needs (including any special needs):

Current Community Concerns / Student Health Issues (Examples: Near by industrial sites or Obesity issues):

Are there any grants that will be utilized to provide these services?

Yes*
No

*If yes, then please list:

Search Team / Wellness Committee:

School personel (type in your list of names):

Parent(s):

LSDMC members:

City Health Department Nurse:
GWC Representative:

Thank you for registering your school, please hit submit form.