Office of Educational Services & Support

Coordinated School Health & Healthy South Dakota

Contact Information:

Contact Name:

Contact E-mail:

School District:

School Name:

Out of School Program Name:

Program Name:

Address:

City:

State: Zip:

Phone:

Fax:

Participant Information:

Age Levels:

# of Student Participants:

Success Story Information:

Success Story Title:

Description of Successful Program/Activity:

Include as many of the following as applicable:
- How the program/activity was developed
- Who/What was the catalyst for getting the activity going
- Public health problem addressed by the program/activity
- Partners involved

Describe Key Results of this Success:

For example:
- Effectiveness of the program
- Build Effective Partnerships
- Establish policies

Quotes/Comments from Participants/Parents/School Staff:

Check if any of the following support materials are being submitted to complement your success story:

	Sample of Materials Produced - Submit Here!
	Press Release - Submit Here!
	Promotional Materials - Submit Here!
	Digital Photos of Project/Event - Submit Here!
	Video/Audio Clip - Submit Here!
	Other: - Submit Here!

Has permission been obtained from the participant(s) to use the photo(s) or video/audio clip(s)?

Yes

School Health

Course Standards:

Special Education

CANS

NEW:

Early Childhood Education

Title

Office Contact Info