If you would like your school to be included in an upcoming Breakin' the
Barriers event, complete the interest form below. One of our event
coordinators will contact you to arrange confirmation. Thank you for
your interest!
Your Email Address:
Your School Affiliation:
Name of School:
Name of Principal:
School Address:
City
State
Zip
School Phone:
BTB School Coordinator:
Complete the following information if you are
prepared to proceed with booking
Select a date and time (choose a 1st, 2nd, and 3rd choice) for
the assembly. If you wish to book more than one BTB assembly,
please enter your 3 choices for additional assemblies in the
comments area at the bottom of the form. Please keep in mind that
assemblies are booked on a "first come, first served" basis.
1st Choice
2nd Choice
3rd Choice
Assembly Length
(Note assemblies can be
as long as 1 hour, or as short as 30 minutes)
Desired Topics
Goal Setting
Courage,Honor,Trust
Academic Excellence
Overcoming Obstacles
Smoking
Anti-drug & Alcohol
Peer Pressure
Suicide
Violence
Respect for Authority
Gang Participation
Teen Pregnancy
Rejection
Other (please specify below)
Sound System
We do have/will secure a sound system for our school assembly
We do NOT have and cannot secure a sound system
Assembly Finances
We can cover the cost ($500) of the assembly from our budget
We need additional assistance in covering the assembly cost
We will use our PTA or other "in-house" means
We will need help through BTB