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* 1. Name

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* 2. School

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* 3. School Address

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* 4. Email

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* 5. School Phone

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* 6. Cell Phone

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* 7. Program Choice

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* 8. Please list any special curriculum requests

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* 9. How many days of programming do you need (1 day= 1 teacher)

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* 10. Please indicate your preferred dates below. Due to many scheduling requests please gives multiple dates. If more than one teacher please give at least 2 dates per teacher.

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* 11. Total number of programs needed per day

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* 12. First program Start Time

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* 13. Last Program End Time

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* 14. Approx. number of students per class

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* 15. Grade Level of Students (click all that apply)

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* 16. What equipment is available for us to use?

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