COUNT ME IN - PreK/K Puppet Show Request

Thank you for your interest in scheduling a COUNT ME IN puppet show at your school! You must enter all contact information (Question 1) in order to submit this form. If you are unsure about how to complete any other questions on the form, you can leave them blank and we will discuss with you when we follow-up on your request. If you have any questions, call PACER at 952.838.9000 or email puppets@pacer.org. Thank you!

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* 1. Please provide your contact information:

Contact Name & Title:

School District:

School Name:

Address:

City:

ZIP:

Main Office Phone:

Contact Email Address:

Contact Phone Number:

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* 2. Please provide billing name and address. Cost is $75 per show.

Name & Title:

Address

City:

ZIP:

Phone Number:

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* 3. How many COUNT ME IN disability awareness shows are you requesting? (Maximum of 3 shows can be presented in 1 day.)

# of shows

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* 4. For each show, list age/grade level (PreK or K) and number of students and adults attending. (Maximum of 60 students per show. 4-6 year olds only - no children younger than 4.)

Show 1 Grade Level

Show 1 # of Students

Show 1 # of Adults

Show 2 Grade Level

Show 2 # of Students

Show 2 # of Adults

Show 3 Grade Level

Show 3 # of Students

Show 3 # of Adults

Show 4 Grade Level

Show 4 # of Students

Show 4 # of Adults

Show 5 Grade Level

Show 5 # of Students

Show 5 # of Adults

Show 6 Grade Level

Show 6 # of Students

Show 6 # of Adults

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* 5. Please provide some information about the site and room where the show(s) will be held. (Room should be quiet, large enough to seat students on the floor in front of our puppet stage, and available 30 minutes ahead of first show for set-up.)

Room name for show

Location for parking

Door to enter

Best place to unload equipment

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* 6. Please list your preferences for date and time of show(s).

Preferred month

Preferred days of week

Preferred time of day

Any dates during selected month that are not available?

Time School begins

Lunchtime(s)

Time School ends

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* 7. Informational letters in English are provided for the students to take home following the presentation. Please check if you would like the letter in any of the following additional languages for you to make copies for your students:

Hmong

Somali

Spanish

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* 1. Please provide your contact information:

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* 2. Please provide billing name and address. Cost is $75 per show.

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* 3. How many COUNT ME IN disability awareness shows are you requesting? (Maximum of 3 shows can be presented in 1 day.)

Question Title

* 4. For each show, list age/grade level (PreK or K) and number of students and adults attending. (Maximum of 60 students per show. 4-6 year olds only - no children younger than 4.)

Question Title

* 5. Please provide some information about the site and room where the show(s) will be held. (Room should be quiet, large enough to seat students on the floor in front of our puppet stage, and available 30 minutes ahead of first show for set-up.)

Question Title

* 6. Please list your preferences for date and time of show(s).

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* 7. Informational letters in English are provided for the students to take home following the presentation. Please check if you would like the letter in any of the following additional languages for you to make copies for your students:

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* 8. Any additional information or special requests?