NOTE: Please complete each item on the form. The form must be be complete so it can be submitted successfully.
Name of Class / Organization:
Today's Date: Contact Person: Telephone Number:
Email Address:
Program / Presentation Requested:
# of students expected to be in attendance: Location: Preferred Date: Alternate Date:
Preferred Time: Alternate Time:
Please complete this form at least two weeks before the "Preferred Date". Programs are about 50 minutes in length. You will be contacted by Tracy Muth to confirm your request
Comments / Special Requests Comments: