Report on Impact Form
Please complete this form to report how many students in your school have been impacted this year with Erika's Lighthouse programs and resources. Thank you!
WordPress ID
First Name
Last Name
Your School
First Name
Last Name
Email Address
Do you want to register for a different School?
Yes
No
School
USA?
Yes
No
Country
Country Copy
School
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School ID NOT USA
State
State Copy
School
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School ID USA
School ID
School Term
YOU MUST SELECT AT LEAST ONE PROGRAM AND INCLUDE NUMBER IMPACTED
CLASSROOM EDUCATION
Format
# Students Impacted
Level I: We All Have Mental Health
(Grades 4-6)
Please select...
1-Day
4-Day
Other
Level II: Depression Awareness
(Grades 5-9)
Please select...
1-Day
4-Day
Other
Level III: Depression Education & Suicide Awareness (Grades 8-12)
Please select...
1-Day
4-Day
Other
OTHER PILLARS
Type
# Impacted
Empowerment Clubs
Please select...
Official Club
Affiliate Club
Family Engagement
Please select...
Family Workshops
Family Workbooks
Awareness into Action Activities for Families
School Policy & Staff Development
Please select...
All Staff Training
Implementation Training
Mental Health Task Force
Staff Wellness Activities
GENERAL INITIATIVES
# Impacted
Schoolwide Campaigns
Please select...
Give Voice Suicide Prevention Week
Positivity Pledge - May
RECHARGE - 5 Minute Breaks
Awareness into Action Activities
Validation
What other programs, besides Erika's Lighthouse, are you using to meet the Four Pillars around mental Health? (Optional)
Classroom Education
Teen Empowerment/Clubs
Family Engagement
Staff Training
Other
Spare Field
Contact Information