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Solutions Request Form
P.O. Box 2083
Clarksville, IN 47129-2083
Phone: 502-523-0535
Toll Free: 877-273-3004
Contact Information
School Year:
2020-2021
2021-2022
2022-2023
2023-2024
2024-2025
2025-2026
2026-2027
2027-2028
2028-2029
2029-2030
Signature Box
Checking this box indicates you have read and agree to the provisions outlined in the
Checklist
for a Successful Solutions Program.
School Name:
Contact Name:
Contact Information:
(Please include Emergency contact for teacher(s) and school.)
Scheduling Date(s):
Bell Schedule
School Day Start:
School Day End:
Special Area Times:
Kindergarten Start:
Kindergarten End:
First Grade Start:
First Grade End:
Second Grade Start:
Second Grade End:
Third Grade Start:
Third Grade End:
Fourth Grade Start:
Fourth Grade End:
Fifth Grade Start:
Fifth Grade End:
Lunch Times
Kindergarten Lunch Begin:
Kindergarten Lunch End:
First Grade Lunch Begin:
First Lunch End:
Second Grade Lunch Begin:
Second Grade Lunch End:
Third Grade Lunch Begin:
Third Grade Lunch End:
Fourth Grade Lunch Begin:
Fourth Grade Lunch End:
Fifth Grade Lunch Begin:
Fifth Grade Lunch End:
Teacher(s)
Mr.
Ms.
Mrs.
Room #:
Email:
Subject
Enter Subject Name:
Grade(s): Select applicable
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Lunch Time(s): Select applicable
Kindergarten Lunch
First Grade Lunch
Second Grade Lunch
Third Grade Lunch
Fourth Grade Lunch
Fifth Grade Lunch
Total Number of Students:
Click To Add Additional Subjects For Same Teacher
Click To Add Additional Teachers
Note: All schools are scheduled on first come - first served basis.
Special Note(s):
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