Request a Program

Instructions: Talks can only be presented between 12:30 and 5:30 p.m. to accommodate student class schedules. Unfortunately, there are no exceptions. The last talk for the 2013-2014 academic year will be on May 16, 2014. Please allow at least two weeks notice after submitting your request. Thank you.


Today's Date:

School:

Address:

City:

Zip:

Contact:

Title:

Day Phone:

Eve. Phone:

E-mail:


Talk #1

Which talk would you like presented?

Grade Level: Number of Students:

Preferred Date: Time:

Special consideratiions, if any:


Talk #2

Which talk would you like presented?

Grade Level: Number of Students:

Preferred Date: Time:

Special consideratiions, if any:


Talk #3

Which talk would you like presented?

Grade Level: Number of Students:

Preferred Date: Time:

Special consideratiions, if any:


Additional talks: (Please provide the same information as above or submit an additional form.)

Comments:

Thank you!