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PREVENTION EDUCATION PROGRAM REQUEST FORM

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School / Organization Information



Programming Requested

Violence Prevention / Social Emotional Learning

Grade / Age Program Focus Length
Primary-Middle
School
Social Emotional
Learning/Bullying
Prevention
Respect & Empathy, Emotion
Management, Communication, Conflict
Resolution, Problem-Solving and
Bullying Prevention and Internet Safety
30 min/week for 12 wks (K-
2nd)
45 min/week for 12 wks (3rd-
8th)
Individuals with
Disabilities
Violence Prevention Self-Esteem, Self-Care, Gender
Inequality, Internet Safety, Conflict
Resolution, Disclosures, Safe
Places/People and Celebrating
Empowerment
60 minutes/week for 10 wks
(Only offered after the
Healthy Relationships
program.)

Healthy Relationships

Middle-High
School
Small Group Facilitated
Sessions
Sessions focus on: Communication,
Emotion Management, Fostering
Responsibility, Relationships and Self-
Development
30 min/week for 12 wks
Middle School-College Relationship Abuse
Prevention
Defining Caring Relationships, Dating
Abuse, Safety Planning, Overcoming
Gender Stereotypes, Managing
Emotions
45 minutes for one to four
sessions
Individuals with
Disabilities
Healthy Relationships Relationships, Boundaries and
Consent, Feelings and Actions, Public
vs. Private Behavior, Sexual Violence
and Safety Planning
60 minutes/week for 3-6 wks

Sexual Abuse Prevention


(Fulfills the State of Illinois Mandate of “Erin’s Law” requiring all schools to provide students with sexual abuse prevention education on a yearly basis.)
PreK – 2nd Body Safety Body Safety Rules and Talking About
Touching
30 minutes
3rd Breaking the Silence: What
is Child Abuse?
Physical Abuse, Sexual Abuse and
Neglect
45 minutes
4th When Should You Tell? Listening to Your Instincts 45 minutes
5th Sexual Harassment
Prevention
How to Recognize and Report Sexual
Harassment
45 minutes
6th Child Sexual Abuse Recognizing and Reporting Child
Sexual Abuse
45 minutes
7th Sexual Harassment Prevention (Part 2) How to Recognize, Refuse and Report Sexual Harassment 45 minutes
8th Sexual Harassment and
Technology
Understanding the power and
consequences of using technology
inappropriately
45 minutes
9th Adolescent Relationship
Abuse
Healthy vs. Unhealthy Characteristics
of Relationships
45 minutes
10th Date Rape Prevention Consent vs. Coercion and Safety
Planning
45 minutes
11th Date Rape Drugs Effects of Date Rape Drugs and Safety
Planning
45 minutes
12th Sexual Harassment and
Relationship Violence
Warning Signs of Abusive
Relationships and Safety Planning
45 minutes
Individuals with
Disabilities
Body Safety Body Safety Rules and Safety Planning 30 minutes



Intended Audience for Student Presentations


(Please note any special needs. Example: hearing impaired, ESL, BED, developmental disabilities, etc.)

Grade # of Classrooms Total # Students Note Special Needs



Scheduling:

Please identify your preferred time frame for programming by Prevention Educators.


Student Presentations:

1st Choice Dates
2nd Choice Dates




School Staff Sexual Abuse Prevention Overview:

(30 min) must occur prior to student education

1st Choice Date
Time
1st Choice Date
Time
# Attending: