Gap Fillers Flathead

Your Name

School Name

Email

Phone

How many students?

Girls?

Boys?

How many girls' bathrooms?

How many girls bathrooms used primarily by ages 10 and up?

Would custodial staff agree to install and stock feminine product dispensers? Would custodial staff agree to install and stock feminine product dispensers? Yes No

Any lunch debt? Any lunch debt? Yes No

How much?

accrued since (month & year)

How is lunch debt currently handled when a student's account is in arrears? Does the student receive an alternative lunch or is the student denied lunch?

How many students identified as on or below poverty line?

Any AEDs?

Epi-Pens?

Are they on recall and/or expired? Are they on recall and/or expired? Yes No

Heart Locker: Heart Locker: Yes No

Notes: