2022-2023 Pretty Brown Girl Academy Request for Services FormThank you for interest in offering Pretty Brown Girl Academy at your school! Please complete this form to receive an invoice or contract for services during the 2022-2023 school year!Your Name *Your Cell Phone Number *Please provide your direct cell phone number for immediate assistanceYour Email Address *Your Title/Position *School Information/ ProfileSchool Name *School Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSchool Phone Number *School Dismissal Time *Principal's Name *Principal's Email Address *Principal's Direct Cell Phone Number *Please provide a direct cell phone number for immediate assistanceDesignated School Contacts/ InformationYour 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 Main Point of Contact (will assist with school protocols, program logistics, scheduling, classroom management, etc.).Billing Contact Name *Billing Contact Email Address *Billing Contact Cell Phone Number *Please provide a direct cell phone number for immediate assistanceMain Point of Contact Name *Main Point of Contact Email Address *Main Point of Contact Cell Phone Number *Please provide a direct cell phone number for immediate assistanceDemographics of ParticipantsWhat are the demographics of the girls we will be serving? Please select all that apply *American Indian or Alaska NativeAsianBlack or African AmericanHispanic/ LatinXNative Hawaiian or Other Pacific IslanderOtherIf "Other", please share. If not applicable, say N/A. *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? *YesNoProgram Information/ Request for ServicesPlease complete the following fields so we can understand the scope of your request.Would you like to nominate a member of the school staff to facilitate our program? *Please selectYesNoPrincipals can nominate official school staff members to facilitate our program. Ideal candidates are those who have a heart for the girls, a bubbly personality, and someone who can relate to the girls on various levels (i.e. culture, trends, etc.). PBG will provide Facilitator Training and a stipend for each facilitated session.If yes, please provide the name, email and direct cell phone number of the staff member(s). If no, please say N/A. *Are you a New or Returning Pretty Brown Girl Educational Partner? *NewReturningReturning Educational Partners are schools who had an active Pretty Brown Girl Club during the 2021-2022 school yearAre you seeking in-person or virtual services? *In-Person (available for 3rd-12th grades)Virtual (available for 3rd-12th grades)Estimated Number of Groups Needed *Multiple groups can be ordered. Each group should serve girls within similar maturity levels (i.e. 3rd grade, 4th-5th grade, 6th-7th grade). PBG will not exceed more than two grade bands with the exception of middle and high school students.Estimated Number of Participants *Note: Each group includes up to 20 girls. There is no limit on the amount of girls that can participate in PBG Academy.Will there be designated classroom(s) to accommodate the total number of groups/participants? *YesNoGrade Levels of Participants (select all that apply) *3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeWhat is your funding source? *Who should the invoice be addressed to? *How will the payment be remitted? *CheckElectronic Payment/ ACHPurchase OrderOtherIf "Other", please share. If not applicable, say N/A. *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: PBG Academy 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 on your request for services. *PhoneSubmit
