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FIND RESOURCES IN YOUR HIGH SCHOOL
Enrollment Form
Please fill out the following questions by entering information into the fields. When you have finished, click the submit button.

This information will be used to develop your school's "Resource Page", which will be made available to your students within High School Blues website. There are no contracts and no commitments. If you determine this program no longer meets your expectations, or need to change information, let us know and we will remove or update the site immediately.

denotes a required field.

1 High School Name
2 Your Name
3 Your Title/Position
4 Your Phone Number
5 Your Email Address
6 School's Mailing Address Line 1:
Line 2:
City:
State or Province:
Postal Code:
Country:
7 Would you consider acting as a program advisor?
Yes
No
8 Would you like to submit content articles to the site?
Yes
No
9 What information would you like to make available to your students via the High School Blues website?
10 Are there key areas you wish to highlight for your students? Check all that apply:
 Alternative School Settings
 Anxiety
 College Planning
 Depression
 Drugs and Alcohol
 Diversity
  Ethnic Groups
 Homosexuality
 Occupational Skills Training
 Pregnancy
 Special Populations
11 Are there local resources you would like your students to know about?
12 Who can students at your school contact for assistance? (list up to three contacts)
  Contact 1:
(You must list at least one contact, even if it is yourself.)
Name:
Title:
Phone Number:
Email Address:
Best time to be reached:
Mailing Address:
Line 1:
Line 2:
City:
State or Province:
Postal Code:
Country:
  Contact 2:
Name:
Title:
Phone Number:
Email Address:
Best time to be reached:
Mailing Address:
Line 1:
Line 2:
City:
State or Province:
Postal Code:
Country:
  Contact 3:
Name:
Title:
Phone Number:
Email Address:
Best time to be reached:
Mailing Address:
Line 1:
Line 2:
City:
State or Province:
Postal Code:
Country:
  Contact 4:
Name:
Title:
Phone Number:
Email Address:
Best time to be reached:
Mailing Address:
Line 1:
Line 2:
City:
State or Province:
Postal Code:
Country:
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