Teacher's Name (required)

Teacher's Email (required)

Grades
Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeOther/Special

Approx. number of students wishing to participate

School Name

School Address

School Phone Number

Please list the info below for who will be the contact person for the class above (may be a parent, teacher, or other appropriate adult)

Name (first and last)(required)

Email (required)

Phone during the day (required)

Alternate Phone

Below please list preferred date and time for CARE lesson. Please note we prefer to facilitate the program during the same day and time each week. If you are requesting multiple lessons Responsibility will be facilitated as the first lesson.

Does your class have any special needs or accommodations?
Yes!No
If yes, please describe

Which animals are able to visit your classroom?
DogCatGuinea Pig

We wish to have CARE for
1 week2 weeks3 weeks4 weeks5 weeks

Lessons
ResponsibilityCaringFairnessRespectCitizenship

Date & Time #1

Date & Time #2

Date & Time #3

Date & Time #4

Date & Time #5

Notes & Comments

Woof! Are you a human?