Request For Services Form

Hit enter to search or ESC to close

Close Search

Who We Are
What We Do
Make An Impact
PBG Foundation
- Become A Sponsor
- Make A Donation
Shop
facebook youtube instagram

Donate

2023-2024 Pretty Brown Girl Program Request for Services Form

"*" indicates required fields

Your Name*

First Last

Your Phone Number*

Please provide your direct cell phone number.

Your Email Address*

School Information/ Profile

School Name*

School Address*

Street Address City State / Province / Region ZIP / Postal Code Country

School Phone Number*

School Dismissal Time*

Principal's Name*

Principal's Email Address*

Principal's Direct Cell Phone Number*

Designated School Contacts/ Information

Your school must identify one staff member to serve as our Billing Contact (will assist with invoicing, POs, billing, etc.) and one staff member to serve as our PBG Liaison (will serve as our main point of contact and assist with program logistics, registration, scheduling, etc.).

Billing Contact Name*

Billing Contact Email Address*

Billing Contact Cell Phone Number*

Please provide a direct cell phone number for immediate assistance

PBG Liaison Name*

PBG Liaison Email Address*

PBG Liaison Cell Phone Number*

Please provide a direct cell phone number for immediate assistance

Demographics of Participants

What are the demographics of the girls we will be serving?*

American Indian or Alaska Native

Asian

Black or African American

Hispanic/ LatinX

Native Hawaiian or Other Pacific Islander

Other

Please select the demographics that apply

If "Other", please share

How will you describe the girls we will be serving?*

Please share any insight and specific details such as climate and culture, energy levels, etc.

Will the participating students need a Bilingual Facilitator?*

Program Information/ Request for Services

Please complete the following fields so we can understand the scope of your request.

Are you a New or Returning Pretty Brown Girl Educational Partner?*

Returning Educational Partners are schools who had an active Pretty Brown Girl Club during the 2022-2023 school year.

Are you seeking in-person or virtual services?*

Please share which classroom(s) or space(s) will be assigned to the group(s).

Grade Levels of Participants*

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Select the Grade Levels that apply

If you ordered for multiple groups, please share the breakdown in the space below. If you ordered for one group, say N/A.*

Note: Elementary groups can not surpass more than two grade bands (i.e. 3rd-4th, 4th-5th).

What is your anticipated program meeting day(s)? Please include a minimum of two days during the week.*

Note: Sessions will run during weekdays only (Monday-Friday).

What is your anticipated program start time?*

Note: The Pretty Brown Girl Program is designed for after-school learning.

What is your anticipated program start date?*

Note: Anticipated start dates are not guaranteed as programs are started in the order in which payments/Purchase Orders are received.

Please provide any additional information and details.*

Name

This field is for validation purposes and should be left unchanged.

Support a movement designed to instill self-confidence and leadership skills in girls of color. Pretty Brown Girl values diversity and does not discriminate on the basis of race, ethnicity, color, religion, or sexual orientation.

Donate

Who We Are
PBG Program
PBG Foundation

Become A School Partner
PBG Scholarships
Sponsor

Become A Facilitator
Contact
Shop

Close Menu

Donate

Who We Are
What We Do
Make An Impact
PBG Foundation
- Become A Sponsor
- Make A Donation
Shop

facebook
youtube
instagram