Name of School Principal (Note: Principal must agree to the application and commitment if your school is selected)
Name of Superintendent
Applicant's Phone Number
Applicant's Email Address
Tell Us About Your School
How many students are in your school?
How many teachers and support staff does your school have?
What percentage of your students are eligible for the free or reduced meal program? (Please note, to be eligible for the Cool Water Program, the school must have 40% or more students eligible for free or reduced meals)
How do the students at your school currently access drinking water during the school day?
Are the students allowed to carry water bottles with them during the school day?
Do you currently have any water bottle filling stations installed at your school?
Yes - unfortunately your school is not eligible at this time
Is your school in a community with optimally fluoridated water? (To find out, visit https://nccd.cdc.gov/DOH_MWF/Default/CountyList.aspx)
Approximately how old is the current water fountain you would like to replace?
Where is the water fountain to be replaced located in your school? (Hallway, near the cafeteria or gymnasium, etc.)
Does the plumbing work properly to your existing water fountain?
Does your current water fountain have working electrical sources?
Does your school participate in a school-based oral health screening, fluoride or sealant program?
If yes, please provide any details on oral health services provided.
Do the students in your school receive any oral health education?
If yes, please provide any details you can about the current oral health education they receive.
Would you be open to inviting news media into your school to showcase kicking off the Cool Water Program campaign and interview students and staff?
Does your school/district have a communications or public relations department or staff person?
If yes, please provide contact information.
Why Your School Should Be Chosen
Explain why your school should be selected as a recipient for a new water fountain/bottle filling station.
How do you think this program would benefit the students and staff at your school?
Would you be willing to distribute educational oral health materials to parents and students?
What is your school's implementation plan to get students to drink more water? Be creative - this is the major factor in our selection process!
Is there anything else we should know about your school and its students?
Please include photos of the current drinking fountain that would be replaced. Your photos should show the front and sides of the existing fountain as well as the surrounding environment (near a doorway, ledge, electrical outlet, etc.) so that the distributors/installers can determine the ideal water filling station as well as installation time/methods.
You may also attach any supporting documentation below. If you have multiple documents, please combine them into one file using a scanner prior to uploading.