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» Dr YES
dr yes registration

Dr YES Online Registration
Use this form to submit a request for the Doctor Youth Education Sessions (Dr YES) to visit your school.

School : (required)
Contact Person : (required)
Address : (required)
Phone Number : (required)
Fax Number :
Email :
Please provide details of the classes you would like us to visit, and the preferred topic(s). You can have up to 3 preferences.
Preference 1
Year : (required) 10 11 12
Number of Students : (required)
Topic : (required) Sexual Health
Alcohol & Other Drugs
Mental Health
Please give details of the preferred time for the sessions. Please be as accurate as possible. We realise that exact days are not known until closer to the time.
Term : (required) 1st
2nd
3rd
4th
Week(s) :
Week 1 Week 2 Week 3 Week 4 Week 5
Week 6 Week 7 Week 8 Week 9 Week 10
Day(s) : Monday
Tuesday
Wednesday
Thursday
Friday
Preference 2
Year : 10 11 12
Number of Students :
Topic : Sexual Health
Alcohol & Other Drugs
Mental Health
Please give details of the preferred time for the sessions. Please be as accurate as possible. We realise that exact days are not known until closer to the time.
Term : 1st
2nd
3rd
4th
Week(s) :
Week 1 Week 2 Week 3 Week 4 Week 5
Week 6 Week 7 Week 8 Week 9 Week 10
Day(s) : Monday
Tuesday
Wednesday
Thursday
Friday
Preference 3
Year : 10 11 12
Number of Students :
Topic : Sexual Health
Alcohol & Other Drugs
Mental Health
Please give details of the preferred time for the sessions. Please be as accurate as possible. We realise that exact days are not known until closer to the time.
Term : 1st
2nd
3rd
4th
Week(s) :
Week 1 Week 2 Week 3 Week 4 Week 5
Week 6 Week 7 Week 8 Week 9 Week 10
Day(s) : Monday
Tuesday
Wednesday
Thursday
Friday
Additional Comments

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