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?
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No
School
USA?
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No
Country
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School
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School ID NOT USA
State
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School
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School ID USA
School ID
School Term
First, select which program(s) you are using in your school this school year. Then, below you will see where to further indicate which type of program and the number of students impacted. You must complete these fields to submit the form
YOU MUST SELECT AT LEAST ONE PROGRAM AND INCLUDE NUMBER IMPACTED
CLASSROOM EDUCATION
Mental Health: Depression & Suicide
Mental Health: Stress & Anxiety
Resilient Mindsets
Positive Relationships
ADDITIONAL SCHOOL PROGRAMS
Empowerment Clubs
Family Engagement
Policy & Staff Training
Schoolwide Campaigns
COMMUNITY PROGRAMS
The Anyone Program
CLASSROOM EDUCATION
Format
# Students Impacted
Mental Health: Depression & Suicide
Introduction: We All Have Mental Health (Grades K-3)
Please select...
Standalone
4-Day
Other
Level I: We All Have Mental Health
(Grades 4-6)
Please select...
Standalone
4-Day
Other
Level II: Depression Awareness
(Grades 5-9)
Please select...
Standalone
4-Day
Other
Level III: Depression Education & Suicide Awareness (Grades 8-12)
Please select...
Standalone
4-Day
Other
Mental Health: Stress & Anxiety
Introduction:
Understanding Stress and Anxiety
(Grades K-3)
Please select...
Standalone
4-Day
Other
Level I:
Understanding Stress and Anxiety
(Grades 4-6)
Please select...
Standalone
Level II:
Anxiety Awareness
(Grades 5-9)
Please select...
Standalone
Level III:
Stress and Anxiety
(Grades 8-12)
Please select...
Standalone
4-Day
Other
Resilient Mindsets
Introduction:
Resilient Mindsets
(Grades 3-K)
Please select...
Standalone
4-Day
Other
Level I:
How to Bounce Back
(Grades 4-6)
Please select...
Standalone
Level II:
Building Resilience
(Grades 5-9)
Please select...
Standalone
Level III:
Resilient Mindsets
(Grades 8-12)
Please select...
Standalone
4-Day
Other
Addiction
Introduction:
Addiction
(Grades 3-K)
Please select...
Standalone
4-Day
Other
Level I:
Addiction
(Grades 4-6)
Please select...
Standalone
4-Day
Other
L
evel II: Addiction (Grades 5-9)
Please select...
Standalone
4-Day
Other
Level III:
Addiction
(Grades 8-12)
Please select...
Standalone
4-Day
Other
Digital Wellness
Introduction:
Digital Wellness
(Grades 3-K)
Please select...
Standalone
4-Day
Other
Level I:
Digital Wellness
(Grades 4-6)
Please select...
Standalone
4-Day
Other
Level II:
Digital Wellness
(Grades 5-9)
Please select...
Standalone
4-Day
Other
Level III:
Digital Wellness
(Grades 8-12)
Please select...
Standalone
4-Day
Other
Positive Relationships
Introduction:
Positive Relationships
(Grades K-3)
Please select...
Standalone
4-Day
Other
Level I:
Positive Relationships
(Grades 4-6)
Please select...
Standalone
4-Day
Other
Level II:
Positive Relationships
(Grades 5-9)
Please select...
Standalone
4-Day
Other
Level III:
Positive Relationships
(Grades 8-12)
Please select...
Standalone
4-Day
Other
Social Inclusion
Introduction:
Social Inclusion
(Grades K-3)
Please select...
Standalone
4-Day
Other
Level I:
Social Inclusion
(Grades 4-6)
Please select...
Standalone
4-Day
Other
Level II:
Social Inclusion
(Grades 5-9)
Please select...
Standalone
4-Day
Other
Level III:
Social Inclusion
(Grades 8-12)
Please select...
Standalone
4-Day
Other
ADDITIONAL SCHOOL
PROGRAMS
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
Schoolwide Campaigns
Please select...
Give Voice Suicide Prevention Week
Positivity Pledge - May
RECHARGE - 5 Minute Breaks
Awareness into Action Activities
COMMUNITY PROGRAMS
Type
# Impacted
The Anyone Program
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