School Partnership Interest Form

Address *
Address
Principal Name *
Principal Name
Phone *
Phone
Additional Staff Contact
Additional Staff Contact
Phone
Phone
School Start Time *
School Start Time
School End Time *
School End Time
Ex. Grade K: X Enrolled Grade 1: X Enrolled etc. through Grade 12
Ex. X% White X% African American X% Hispanic X% Native American X% Asian X% Other
Ex. X% English only X% English and Spanish X% Spanish only X% Other (Specify)
8. For which grade levels do you hope to offer 21st AVE afterschool programs? (Check all that apply): *
9. Preferred start date: *
9. Preferred start date:
10. Preferred end date: *
10. Preferred end date:
11. At what time do you prefer your 21st AVE program to begin? *
11. At what time do you prefer your 21st AVE program to begin?
12. Which day(s) do you prefer your 21st AVE program to operate? (Check all that apply): *
13. When would you prefer your 21st AVE program to operate? (Check all that apply): *
23. Please select which activities you might like to have at your school during afterschool: