Schools & Childcares Interest Form

Let us know if you’re interested the PWD Schools & Childcares Lead Sampling Program

All items marked with an asterisk (*) are required fields. If you have any questions, or to fill out the survey over the phone, please call (215) 685-1407.

Estimated time to complete: 1 minute

Name *

Email Address *

Phone Number *

Are you the best person at your facility to be our primary contact? *

The primary contact should be someone who we can ask about the building’s plumbing, will be present for our walk-through, and will follow our instructions to collect water samples from the outlets we identify. This may be the owner/operator of a small childcare, a janitor or facilities manager at a school, or someone else who is familiar with the plumbing and available to assist. We can provide the sampling results and guidance to other people, if needed.

Primary Contact Name *

Primary Contact Email Address *

Primary Contact Phone Number *

Name of School or Childcare Facility *

Is your facility interested in participating in PWD’s Schools & Childcares Lead Sampling Program? *

Yes, we’re ready to participate
Yes, but not right now
Maybe
No

No problem, we can reach out again later. When do you think you might be ready? *

Later this semester/season
Next semester
Next year