Please note: Requests must be made at least 3 weeks in advance.
Teacher/Contact Name:
School Name:
School Address:
City:
ZIP Code:
School Phone:
Home/Cell Phone:
E-mail Address:
Grade Level:
Single classroom visits are $100 with a maximum of 60 students per presentation. Each additional presentation at the same location on the same day is $50. Title I Schools receive a 50% discount.
How many separate presentations do you need on the day of the visit?
How many total children will view the presentation on the day of the visit?
Title I School:
Choose one presentation:
First choice presentation date (Enter your response as Month/Day/Year; Ex: July/01/2010):
Second choice presentation date (Enter your response as Month/Day/Year; Ex: July/01/2010):
Please provide any additional information you think might be helpful to our Outreach Teacher:
Preferred time of presentation:
