JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
ARMED Request Form
Please fill out this form to request an ARMED presentation from CHS Youth and Family Connections Program. After submission, we will be in touch to confirm details. Any questions, please contact Maddie Hinkle at
CHSYouth@anixter.org
. Thank you!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Your Name and Title
*
Your answer
Name of School/Program
*
(Where the presentation will be hosted)
Your answer
Name of Classroom Teacher
*
(Classroom teacher who will handle the logistics of the ARMED visit)
Your answer
Address of School (street, city, state, zip)
*
(Where the presentation will be hosted)
Your answer
Phone (text, landline, VP?)
*
(Please list and label any phone numbers we can use to contact you)
Your answer
Email
*
Your answer
What is the best way to contact you?
*
Email
Phone call
Text
Any of the above is fine
What kind of presentation?
*
ARMED (Adult Role Models in Education of the Deaf)
READ (story-sharing with students)
Number of Students?
*
(Approximate number of students we would present to)
Your answer
Grade Level of Students
*
(Select all that apply, which grade levels you would like us to present to)
Early Childhood (PreK-K)
Lower Elementary (1st-3rd)
Upper Elementary (4th-5th)
Middle School (6th-8th)
High School (9th-12th)
Transition Program
Other:
Required
Would you prefer the presentation to be in person or virtual?
*
In person
Virtual
Either
Do you want a one-time or regular presentations?
(You can request one-time presentations as many times as you need)
*
One-time
Every other month
Other:
If regular presentations, do you want the same presenter or different presenters?
Same presenter to develop a relationship with the students.
Different presenters to learn about different careers / experiences.
Other:
Clear selection
Please list THREE (3) preferred dates for us to attend
*
Your answer
What time blocks are preferred for your students?
*
Your answer
What communication needs do your students have?
(Do you need voice or sign interpreters? If so, does your program have interpreters or do you need CHS to provide them?)
*
Your answer
What topic/area would you like the presenter to talk about?
*
(Select all that apply)
Deaf culture and Deaf identity
Developing communication strategies
Current assistive technology
Importance of staying in school/working hard/grades
Importance of self-advocacy, knowing your rights, standing up for yourself
Career options
College/vocational school options
Communication with family, teachers, and counselors about future plans
Other:
Required
What types of occupations are you interested in? Please list specifics if you know them. If open to any, then state that.
*
(We will try to match our ARMED presenter with your student group interests)
Your answer
Any other information you'd like to share?
*
Your answer
Are you interested in collaborating with other schools and programs for group events?
This is separate from ARMED.
Yes!
Not at this time.
Clear selection
Are you interested in any of our free, Special Topic Presentations?
This is separate from ARMED. We will follow up with more details.
Consent and Body Boundaries (Pre-K - Elementary)
Consent and Relationships (Middle School - High School)
Elections and Voting (High School - Transition)
Identity Theft and Fraud Prevention
Professional Development for Staff
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
