Name of School (No Abbreviations) School is a:Please select... Middle School High School College/University School System/District Nonprofit Other Name of District In which state is your district located?Please select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Other (Outside U.S.) Other State: School Contact First Name School Contact Last Name Email RolePlease select... Administrator Campus Wellness Staff Chapter Advisor Counseling Center Director Employee/Staff Faculty Student Title Is your school a Title I school? Please select... Yes No Does your school have an Active Minds Chapter?Please select... Yes No What setting do you plan on facilitating the Active Minds Peer-Powered Curriculum?Advisory PeriodHealth ClassAnother Class PeriodActive Minds Chapter meetingsAnother student organization meeting (please list)Other Other What grade level(s) do you plan on facilitating the curriculum with (check all that apply):All grades9th10th11th12th Approximately how many students will receive the curriculum? Contact Information
